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APLASTIC ANEMIA IN THE PHILIPPINES Honorata G. Baylon, MD, MHA, FPCP, FPSHBT
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APLASTIC ANEMIA IN THE PHILIPPINES
Honorata G. Baylon, MD, MHA, FPCP, FPSHBT
NO DISCLOSURE
https://christinehornnet.files.wordpress.com/2014/11/southeast-asia-colonial-powers-small.jpg
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The Philippines is a Southeast Asian country located in the Far East and bounded by body of water at all sides.
LUZON
VISAYAS
MINDANAO
https://en.wikipedia.org/wiki/Administrative_divisions_of_the_Philippines
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Our country is also called the Philippine Archipelago because it is made up of 7400 islands (used to be only 7107) grouped together into a lovely and sexy land formation. There are 3 main groups of islands – Luzon where the capital Manila is located, Visayas where Boracay island famous for its white beaches can be found and Mindanao where the city of Davao, the 9th safest city in the world is located and where our current Miss Universe Pia Alonzo Wurztbach grew up. The country is divided into several administrative regions and the National Capital Region in Luzon is the smallest but the busiest and populous metropolis where the seat of the government is located.
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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To date, there is no formal registry of aplastic anemia cases in the country but only separate institutional reports.
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
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
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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The survey was done only through self reporting of hematologists so it is most likely that the incidence depicted here is highly underestimated. Nevertheless, it can be inferred that the incidence of aplastic anemia in the country will not be any lower than 1.3 per million. We adjusted for the increase in population from 2010 to 2015 using the UN population data.
Age At Diagnosis (n=484)
118
71
3748
69 72 69
<18 19-30 31-40 41-50 51-60 61-70 >71
Gender Distribution (n=484)
Frequency Proportion (%)Male 252 52
Female 232 48
Severity of Aplastic Anemia (n=484)
11925%
19139%
16233%
123%
Moderately SevereSevereVery SevereData Not Available
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)
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
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
Immunosuppressive Therapy
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
Non-HSCT Modality
• CyA + Eltrombopag• ATG + Eltrombopag• ATG + CyA + Eltrombopag
COST of Eltrombopag – max of 150mg a day – USD 40,000/yr
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
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
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
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.
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.
Acknowledgement
