key: cord-0064845-asjdiqf1
authors: Vallejo Llamas, Juan Carlos
title: Management of aplastic anemia during the phase of defervescence of the COVID-19 pandemic()
date: 2021-06-23
journal: Med Clin (Engl Ed)
DOI: 10.1016/j.medcle.2021.02.003
sha: c460920370e5e90f6921c2eaa4dc3296c55d0601
doc_id: 64845
cord_uid: asjdiqf1

nan

Calcineurin inhibitors (CNI). Its use could confer protection against the development of the most severe forms of COVID-19. This seems to be due to its potential inhibitory effect on viral replication and, above all, to the modulation of the host's excessive immune response to infection 3 . Therefore, the use of cyclosporine A (CsA) or tacrolimus would be suitable for patients who require it.

Eltrombopag (EPAG). This is approved by the FDA and the EMA for patients refractory to immunosuppressive treatment (second line), and by the FDA for patients with MA without previous treatments (first line) who are not candidates for transplantation. No adverse effects of EPAG have been reported on the progression of the SARS-CoV-2 infection, so it should be considered a safe drug in the current epidemiological context. Antithymocyte globulin (ATG). Increased infectious morbidity is a well-known adverse effect of the use of ATG. However, there are no specific data regarding SARS-CoV-2. Therefore, although it is logical that its administration was limited during the maximum effervescence of COVID-19, at the present time it seems reasonable to use it, provided that the expected risk/benefit ratio is favourable.

Triple therapy (ATG/CsA/EPAG). The use of this combination of drugs has resulted in the best results in MA, in the shortest time 4, 5 . Today, it is more important than ever to be able to free patients from their transfusion needs and hospital dependency. Therefore, the use of triple therapy in the different lines, whenever possible, should be a priority.

Bone marrow transplant (BMT). HLA-identical sibling BMT is the first-line treatment of choice for patients under 40 years of age with very severe, severe, and less severe MA with transfusion requirements or infections 1 . BMT should be offered immediately to newly diagnosed patients and to those who may have been on a waiting list for the past few months. In other words, the sooner the candidate patients are transplanted, taking advantage of this phase of improvement in the epidemiological situation of the SARS-CoV-2 pandemic, the better for their cure options. Regarding the indication of BMT (from HLA-identical siblings or from alternative donors) in second or subsequent therapeutic lines, the reasoning would be similar. If the indication is BMT, the procedure should be carried out as soon as possible. There is no need for the transplantation methodology (source of progenitors, conditioning, prophylaxis against GVHD, duration of immunosuppression, etc.) to vary from other situations.

Hospital care for patients with MA, once in the outpatient phase, should be limited to essential actions and be supplemented with telemedicine, whenever possible. The initial management of febrile neutropenia should, however, be performed in the hospital setting 6,7 .

Patients must, of course, comply with the rules applicable to the general population regarding social distancing, the use of masks, hand hygiene, and so on. These practices should be observed until, in one way or another, group immunity against SARS-CoV-2 is achieved, although this does not seem likely to occur in the short term.

Like everyone else, MA patients can catch COVID-19. Therefore, a high index of suspicion should be maintained against this possibility when compatible symptoms are presented (fever, cough, fatigue, etc.) 8 .

MA is a medical emergency and, as such, its treatment should be started as soon as possible after its diagnosis. This is particularly important in cases involving infections, profound neutropenia, and/or increased transfusion requirements. Therefore, the treatment of patients with MA must be prioritised in our current epidemiological situation. And this should be applicable to both newly diagnosed MA patients and those who may have received temporary suboptimal management over the past months. The attitude to follow in the near future will be marked by the course of the pandemic.

En: Manual de Eritropatologiá. Madrid: Ambos Ed

First line treatment of aplastic anemia with thymoglobuline in Europe and Asia: Outcome of 955 patients treated 2001-2012

Why choose cyclosporin A as first-line therapy in COVID-19 pneumonia

Treatment optimization and genomic outcomes in refractory severe aplastic anemia treated with eltrombopag

Eltrombopag added to standard immunosuppression for aplastic anemia

J o u r n a l P r e -p r o o f