Warm Autoimmune Hemolytic Anemia After Mycophenolate or Erythropoiesis-Stimulating Agent Failure
This protocol addresses warm autoimmune hemolytic anemia (wAIHA) in patients who have not achieved adequate hemoglobin response following prior lines of treatment, including mycophenolate (MMF) or an erythropoiesis-stimulating agent.
Prior Treatment — Failure Condition
The preceding line used mycophenolate (MMF) in those with a prior corticosteroid response, or an erythropoiesis-stimulating agent (darbepoetin alfa) in those without an adequate corticosteroid response or following MMF failure.
Escalation to this protocol is triggered by failure to reach a hemoglobin level greater than 10 g/dL or a rise of at least 2 g/dL from baseline.
Next-Line Approach — Overview
For patients with wAIHA refractory to prior therapy, the approach centres on reassessing the diagnosis and, where appropriate, prioritising enrolment in clinical trials — the full protocol details the specific options and the conditions under which a surgical approach may be reserved.
Treatment Target
The clinical goal is a hemoglobin level above 10 g/dL with an increase of at least 2 g/dL from baseline.
References
DOI: 10.1182/hematology.2022000405
- Our subsequent preference is for clinical trials, such as those with fostamatinib, rilzabrutinib, or a neonatal Fc receptor inhibitor.
- She entered a clinical trial with fostamatinib and has been maintained on 150 mg twice a day for 2 years with an Hgb level of 12 g/dL off prednisone.
- Laparoscopic approaches are preferred.
- While not averse to splenectomy, this is usually reserved for those highly refractory to the therapeutic modalities described above and for whom clinical trials are not appropriate.
- Fostamatinib increased Hgb to a level above 10g/dL, with an increase of 2g/dL in 11 of 24 (46%) refractory wAIHA patients; Hgb improvement was often seen after 2 weeks and was maintained with few adverse events.
View source ↗