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Answer 5
  1. ATG with cyclosporine. This patient’s hypocellular bone marrow and declining blood counts are consistent with aplastic anemia. Some studies describe marrow aplasia after treatment with fludarabine and cyclophosphamide, but the cause is unclear. A possible link between T-cell suppression and emergence of autoreactive lymphocytes has been suggested. Given the patient’s age, first-line therapy would be a combination of cyclosporine and ATG. Overall response rate with this therapy is 50% to 60%.2,5 Azacitidine is used to treat MDS, not aplastic anemia. Supportive care alone is not recommended for patients with aplastic anemia, as outcomes are extremely poor.

    2. Kahl C, Leisenring W, Deeg HJ, et al. Cyclophosphamide and antithymocyte globulin as a conditioning regimen for allogeneic marrow transplantation in patients with aplastic anaemia: a long-term follow-up. Br J Haematol 2005;130:747–51.

    5. Frickhofen N, Heimpel H, Kaltwasser JP, Schrezenmeier H. Antithymocyte globulin with or without cyclosporin A: 11-year follow-up of a randomized trial comparing treatments of aplastic anemia. Blood 2003;101:1236–42

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