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APLASTIC ANEMIA IN THE PHILIPPINES
Honorata G. Baylon, MD, MHA, FPCP, FPSHBT
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NO DISCLOSURE
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https://christinehornnet.files.wordpress.com/2014/11/southeast-asia-colonial-powers-small.jpg
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LUZON
VISAYAS
MINDANAO
https://en.wikipedia.org/wiki/Administrative_divisions_of_the_Philippines
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Aplastic Anemia in the Philippines
• No formal registry to date; institutional reports only-3 year prospective study done at UP-PGH Adult Hematology section 1979-1981=70 new cases of aplastic anemia- 6 year review of the patient census of UP-PGH Adult Hematology section 2010-2015= 80 new cases of aplastic anemia
• Survey
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Objectives of the Survey
• To determine the demographics and clinical profile of patients with aplastic anemia in the Philippines
• To determine the range of therapeutic modalities used in the treatment of aplastic anemia patients in the country
• To recommend treatment options in the management of aplastic anemia in developing countries
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Methods• We contacted members of the Philippine Society of
Hematology and Blood Transfusion across the archipelago via phone and email from Dec 2015 to Feb 2016
• We requested for data of confirmed aplastic anemia cases seen from 2010 to 2015
• Currently, 136 PSHBT members and 70% responded to the survey
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Geographic Distribution Of Aplastic Anemia In The Philippines Per Island Group From 2010 -2015 (N=484)
Frequency Proportion (%)
117 24.17
242 50.00
30 6.20
95 19.63MINDANAO
VISAYAS
National Capital Region
LUZON 33
66
27
9
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6.1 5.89
8.58 9.03
7.07
12.51
0
2
4
6
8
10
12
14
2010 2011 2012 2013 2014 2015
Inci
denc
e
Incidence Of Aplastic Anemia In The Philippines From 2010 To 2015 (Per 10,000,000 Population)
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Age At Diagnosis (n=484)
118
71
3748
69 72 69
<18 19-30 31-40 41-50 51-60 61-70 >71
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Gender Distribution (n=484)
Frequency Proportion (%)Male 252 52
Female 232 48
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Severity of Aplastic Anemia (n=484)
11925%
19139%
16233%
123%
Moderately SevereSevereVery SevereData Not Available
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Etiology of Aplastic Anemia (n=484)
Frequency (%)Acquired 439 (90.7)
Idiopathic 400 (91.1)Exposure to chemicals and drugs 22 (5.0)Autoimmune 5 (1.1)Pregnancy 6 (1.4)Hepatitis 6 (1.4)
Constitutional (Fanconi) 1 (0.2)Data not available 45 (9.1)
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Treatment received (n=484)
Frequency Proportion (%)Bone marrow transplant 2 0.4Immunosuppressives (ATG, Cyclosporine regimens)
171 35.3
Androgen ± steroids 82 16.9Steroids ± others 83 17.1Others (EPO, GCSF, Eltrombopag) 3 0.6Supportive care only 89 18.4Data not available 54 11.2
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Immunosuppresives (n=171)
Frequency Proportion (%)ATG + CyA 19 11.1ATG alone 2 1.2ATG + others 3 1.7Cyclosporine only 74 43.3Cyclosporine + androgen 25 14.6Cyclosporine + steroids 44 25.7Cyclosporine + others 4 2.3
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Status as of Dec. 2015 (n=484)
19139%
12225%
11524%
5612%
AliveExpiredLost To Follow upData Not Available
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Immunosuppressive Therapy
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Estimated Cost of Treatment
TREATMENT MODALITY RESPONSE RATE COST (USD)BMT 75-85% 100,000-150,000ATG + CyA 60-80% 15,000- 20,000ATG only 40 - 50% * 8,000 – 10,000CyA only 50 – 60% ** 4,000 – 6,000/yrAndrogen only
IS + Androgen
46% ^
86% ^^
2,500 – 3,000/yr
6,500 – 9,000/yr
*Bacigalupo A, et al. Sem in Hematol 37:69-80, 2002**Yamazaki H ,et al.Intl J Hematol 85:186, 2007^Jaime-Perez, JC et al. Ann Hematol. 90:523-7, 2011^^Ramos-Penafiel CO, et al. Rev Med Hosp Gen Mex, 78:107-111, 2015
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Non-HSCT Modality
• CyA + Eltrombopag• ATG + Eltrombopag• ATG + CyA + Eltrombopag
COST of Eltrombopag – max of 150mg a day – USD 40,000/yr
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Non-Severe Aplastic Anemia
• CyA + Levamisole * - 2 yr EFS 57-86%
• CyA + Glycyrrhizin** - Overall response in 4 mo. 82.86%
*Ren Cui-ai et al. Chinese Med J 2013;126**Xingxin Li et al. Ann Hematol.2013;92:1230
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Algorithm for initial management of SAA. In patients who are not candidates for a matched related HSCT, immunosuppression with horse
ATG plus cyclosporine should be the initial therapy
Phillip Scheinberg, and Neal S. Young Blood 2012;120:1185-1196
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Proposed Algorithm for Initial Management of Aplastic Anemia in Developing Countries
Severe
Age <40
With Donor
Yes
Affordability
Yes
HSCT
No
No
Affordability
Yes
ATG + CyA
IST + Eltrombopag
No
CyA Alone
CyA + Androgen
Androgen Alone
Cya + other agent
Age >40
Non HSCT options
Non Severe
Non HSCT options
Affordability
Yes
ATG + CyA
IST + Eltrombopag
No
CyA Alone
CyA + Androgen
Androgen Alone
CyA + other agent
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Summary• The age and gender incidence of aplastic anemia in the
Philippines are similar to epidemiologic studies done in other countries.
• There appears to be more severe aplastic anemia cases in our country.
• Aplastic anemia cases are more likely to be seen at the National Capital Region of the country simply because of the presence of more hematologists in the area.
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Summary
• The management of aplastic anemia is an unmet medical need in the country.
• The cost is a major factor why BMT and IST are not standard care in the country.
• There is a need to improve data gathering and to do RCTs using cheaper drugs like cyclosporine combined with androgen or with other affordable agents that can harness the immunosuppressive effect.
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Acknowledgement