Immunosuppressive therapy in severe aplastic anemia

Severe aplastic anemia, a disease characterized by pancytopenia and a hypocellular marrow, is treatable by either immunosuppressive therapy (IST) or hematopoietic stem cell transplant. Much is understood about the immune-mediated pathophysiology of AA now, but the inciting factor remains elusive. Many groups around the globe contributed to understanding the disease pathophysiology and optimizing the IST regimen. Horse antithymocyte globulin and cyclosporine, the initial IST regimen, achieved a hematologic response rate in about 60% to 65% of treated patients, with less than 10% achieving a complete count recovery. However, adding a thrombopoietin receptor agonist, eltrombopag (EPAG), to IST improved these response rates to nearly 80% and an unprecedented increase in complete response to almost 40%. The latest report indicates that a high-risk clonal evolution to myeloid malignancies is not increased with hematopoietic stem cell stimulation by adding EPAG in the front line setting. Despite the great success of IST and EPAG in improving early outcomes, relapse remains a problem. Further optimization of upfront therapy and treatment protocol is needed to prevent relapses and decrease clonal evolution rates for even better long-term results.