Prediction of the Depressive Effects of Interferon Alfa Therapy by the Patient's Initial Affective State

Abstract

To the Editor: The study by Leon et al. (Dec.3 issue) 1 comparing three antithrombotic-drug regimens -aspirin alone, aspirin and warfarin, and aspirin and ticlopidineafter coronary stenting showed a lower rate of stent thrombosis with aspirin and ticlopidine, although there were more hemorrhagic complications than with aspirin alone.By contrast, there were no significant differences in the incidence of neutropenia or thrombocytopenia among the three regimens (overall incidence, 0.3 percent).Despite the absence of severe hematologic dyscrasias in the study, the authors refer to reports of the risk of serious hematologic complications, such as thrombotic thrombocytopenic purpura, among patients who received ticlopidine after coronary stent placement.However, they did not mention the risk of aplastic anemia, a life-threatening condition that may be induced by ticlopidine.Recently, Yeh et al. reviewed the cases of ticlopidine-induced aplastic anemia published in the English literature, 2 and four other cases have been reported 3,4 (including one case reported by us).Ten of 23 patients died (43 percent): 7 because of infection (candidal and gram-negative sepsis) and 1 from massive gastrointestinal bleeding.The only factor significantly correlated with survival was the patients' age.Other factors, such as sex, duration of ticlopidine use, and the presence of agranulocytosis at onset, had no prognostic value. 2 Although the pathogenesis of marrow toxicity related to this drug is still unclear, both direct toxicity and immunologic effects have been proposed. 2The therapeutic use of hematopoietic growth factors has been suggested, 4 but this treatment seems to have little effect on survival. 2,3n summary, although it is an infrequent event, ticlopi-dine-induced marrow aplasia is possible, and patients and doctors should be aware of it.However, aplastic anemia, like other hematologic dyscrasias induced by ticlopidine, appears after 2 weeks of treatment, 2-4 whereas stent thrombosis generally occurs within the first 14 days after coronary stenting (a mean of 0.7 day in the study by Leon et al.). 1 So, we agree with the suggestion made by Leon et al.to shorten the duration of ticlopidine therapy after stenting to two weeks.