How should I monitor a patient with aplastic anaemia for potential complications during treatment?

Monitoring a patient with aplastic anaemia during treatment involves assessing for complications related to the disease itself, its treatments (such as immunosuppressants and erythropoietin-stimulating agents), and supportive care like blood transfusions.

• Monitoring related to Immunosuppressive Therapy:
  • If the patient is on azathioprine, monitor their Full Blood Count (FBC), renal function (creatinine/calculated GFR), and Liver Function Tests (LFTs: ALT and/or AST and albumin) every 2 weeks until the dose is stable for 6 weeks, then monthly for 3 months, and thereafter at least every 12 weeks ². More frequent monitoring is required for people at higher risk of toxicity or if the dose is increased ².
  • If the patient is on ciclosporin, monitor their FBC, renal function (creatinine/calculated GFR), LFTs (ALT and/or AST and albumin), blood glucose, and blood pressure every 2 weeks until the dose is stable for 6 weeks, then monthly ². For patients stable for 12 months, reduced monitoring frequency (every 3 months) can be considered on an individual basis ². Monitor more frequently in people at higher risk of toxicity or if the dose is increased ².
• Monitoring for Anaemia and Erythropoietin-Stimulating Agent (ESA) Response:
  • If erythropoietin analogues are used, monitor haemoglobin (Hb) every 2 to 4 weeks during the induction phase of ESA therapy and every 1 to 3 months during the maintenance phase ⁴. Monitor Hb more frequently after an ESA dose adjustment ⁴.
  • Pure red cell aplasia (PRCA), a specific type of aplasia, is indicated by a low reticulocyte count, together with anaemia and the presence of neutralising antibodies ⁴. PRCA is confirmed by the presence of anti-erythropoietin antibodies together with a lack of pro-erythroid progenitor cells in the bone marrow ⁴. Consider specialist referral for people with ESA-induced PRCA ⁴.
  • If an underlying haematological disorder is suspected, particularly in cases of ESA resistance, consider referring the patient to a haematology service ⁴.
• Monitoring for Bleeding Complications:
  • An unexplained fall in haemoglobin and/or haematocrit may indicate occult bleeding ¹. Patients should be carefully monitored for signs of bleeding ¹. Counsel patients on the signs and symptoms of bleeding ¹.
• Monitoring for Iron Overload:
  • To prevent iron overload, especially in patients receiving frequent blood transfusions, carry out routine monitoring of iron stores using serum ferritin at intervals of 1 to 3 months ⁴.
• General Monitoring:
  • Regular full blood count and renal function tests are important for monitoring haematological conditions ⁶.