Hematologist
CION Cancer Clinics
ATG and immunosuppressive therapy for aplastic anaemia | CION Cancer Clinics
ATG (anti-thymocyte globulin) treats aplastic anaemia by calming the immune cells that attack your bone marrow. It is given by drip in hospital over several days, with ciclosporin tablets for many months after. It often takes months to show whether it has worked. This page explains who it suits, who it does not, what the course involves and what to watch for. At CION Cancer Clinics, our haematologist cares for anaemia, bleeding, clotting and inherited blood disorders, with ArogyaSri, CGHS and cashless insurance accepted.
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Medically reviewed by Dr. Basudev PokhrelConsultant Haematologist · last reviewed September 2026, next review due September 2027
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On this page
- What is ATG treatment for aplastic anaemia?
- Who is ATG offered to, and who is it not for?
- What happens during an ATG course?
- What do the words on your treatment plan mean?
- How long before you know whether ATG has worked?
- What do families often get wrong about ATG?
- Common questions about ATG for aplastic anaemia
The short answer
What is ATG treatment for aplastic anaemia?
ATG is a medicine that calms down the immune cells attacking your bone marrow, so the marrow gets a chance to start making blood again. It is given through a drip in hospital over several days, and it is almost always paired with a second medicine, ciclosporin, taken by mouth for many months afterwards.
Why the immune system is the target
In most adults with aplastic anaemia (a condition where the marrow stops making enough red cells, white cells and platelets), the marrow itself is not damaged beyond repair. Your own immune cells, called T cells, have turned on the stem cells that make blood. ATG stands for anti-thymocyte globulin. It is an antibody that removes many of those T cells from your blood. Together, ATG and ciclosporin are called immunosuppressive therapy, or IST, on most reports.
Where eltrombopag fits in
Many haematologists now add a tablet called eltrombopag to ATG and ciclosporin for severe disease. It pushes the remaining stem cells to work harder. Whether it is added for you depends on your age, your counts and what your team can access.
This page explains how the treatment works in general. It cannot tell you whether ATG is right for you. Only a haematologist who has seen your marrow report can do that.Is it for you?
Who is ATG offered to, and who is it not for?
The choice between ATG and a stem cell transplant is the biggest decision early on. Your age, how severe the disease is and whether a matched donor exists all shape it.
Often offered first
Older adults with severe or very severe aplastic anaemia, where a transplant carries more risk. Also people of any age who have no matched brother or sister to donate stem cells.
Sometimes offered
People with milder, non-severe disease who still need regular blood or platelet transfusions. The aim is to reduce how often they need them.
Usually not the first choice
Children and younger adults who have a fully matched brother or sister. For them, a transplant is usually discussed first, because it replaces the marrow rather than relying on it to recover.
Not suited
ATG does not help when the marrow failure is inherited, because the immune system is not the cause.
Checked before starting
- Fanconi anaemia and other inherited causes
- Early bone marrow cancers that look similar
- An infection that is not yet under control
Not sure whether this applies to you?
Ask an oncologistStep by step
What happens during an ATG course?
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Tests before the decision
Your team confirms the diagnosis with a marrow biopsy (a small sample of marrow taken from the hip bone). They also check for PNH cells, inherited causes and hidden infections.
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Getting ready in hospital
A thin tube is usually placed in a large vein for the drips and blood tests. You may be given platelets first, so your count is safer before the drip starts.
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The ATG drips
ATG runs slowly into the vein, once a day, over several days. Steroid medicines are given alongside to soften reactions. Nurses check your temperature, pulse and blood pressure closely.
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Ciclosporin begins
Around the same time you start ciclosporin by mouth. Its level in your blood is checked often, because too little does not work and too much can strain the kidneys.
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Going home
Once reactions have settled and your counts are safe enough, you go home. Transfusions and medicines to prevent infection usually carry on for a while.
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Regular reviews
Blood counts are checked often at first, then less often as things settle. Ciclosporin is reduced slowly, only on your haematologist's advice.
!
One thing that cannot wait
After ATG your white cells can be very low, and an infection can become serious within hours. If you or your parent has a fever, starts shivering, feels suddenly very unwell or is bleeding and it will not stop, go to the nearest emergency department now or call 108. Say that they have aplastic anaemia and have recently had ATG. Do not wait for the morning clinic.
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On your discharge summary
What do the words on your treatment plan mean?
- hATG or rATG
- ATG made from horse (h) or rabbit (r) antibodies. Horse ATG is generally used for a first course; rabbit ATG is more often used for a second one.
- IST
- Immunosuppressive therapy. The combination of ATG and ciclosporin, sometimes with eltrombopag.
- Ciclosporin level
- A blood test showing how much ciclosporin is in your blood. Your team uses it to adjust the amount. Never change it yourself.
- Serum sickness
- A delayed reaction to the horse or rabbit proteins in ATG. It causes joint pain, rash and fever, and is treated with steroids.
- Irradiated blood
- Blood and platelets treated with radiation so donor white cells cannot harm you while your immune system is lowered.
- Response
- Your counts rising enough that you need fewer or no transfusions. A partial response still means less time in hospital.
The waiting months
How long before you know whether ATG has worked?
ATG works slowly. Most people see no change in their counts for the first few months, and that is expected. Transfusions carry on while the marrow recovers, so needing blood soon after treatment does not mean it has failed.
What signs of response look like
The first sign is usually needing blood or platelets less often. Your haemoglobin (the part of red cells that carries oxygen) holds steady for longer between transfusions. Some people's counts return close to normal. Others improve enough to stop transfusions without fully normal counts.
The side effects that matter most
Reactions during the drip are common: fever, chills, rash and a drop in blood pressure. Serum sickness can follow a week or two later. Ciclosporin can raise blood pressure, affect the kidneys, thicken the gums and cause extra hair growth. Infection is the most serious risk, so you will be given medicines to prevent it. Take them exactly as prescribed.
If it does not work, or the counts fall again
There are still options. A second course of ATG, a transplant from a matched unrelated or half-matched family donor, or other medicines may be discussed. That is why reviews continue for years.
Your blood tests after ATG are read as a trend over months. One low result on its own rarely changes the plan.Commonly believed
What do families often get wrong about ATG?
"Still needing blood after ATG means it has failed."
ATG takes months to show its effect. Needing transfusions in the first weeks and months is normal. Response is judged only after enough time has passed.
"The counts are better now, so the tablets can stop."
Stopping ciclosporin suddenly is one of the commonest reasons counts fall again. It is reduced very slowly, over many months, and only when your haematologist decides. Keep taking it until they tell you otherwise, even if you feel well.
"ATG is a kind of chemotherapy, so hair will fall out."
ATG is an antibody that works on the immune system. It does not cause the hair loss people link with chemotherapy. Ciclosporin can actually cause extra hair growth on the face and body, which usually settles once the dose is lowered.
"If a transplant is possible, ATG is the weaker option."
Neither is simply stronger. A transplant replaces the marrow but carries its own serious risks. ATG avoids those risks but relies on your marrow recovering. The right choice depends on your age, donor and severity, and it is worth a second opinion.
Questions we are asked
Common questions about ATG for aplastic anaemia
How many days will I need to stay in hospital for ATG?
The drips themselves run once a day for several days. Most people stay in hospital a little longer than that, until the reactions settle and counts are safe enough to go home. The exact stay depends on how your body handles the drips and on any infection. Your team will give you a clearer idea before admission.
Does ATG work for everyone with aplastic anaemia?
No. Many people respond well, some respond partly and some do not respond at all. It does not help inherited marrow failure such as Fanconi anaemia. Nobody can tell in advance exactly how you will respond. Your haematologist can explain what in your own reports makes a response more or less likely.
What is serum sickness, and when does it happen?
It is a delayed reaction to the animal proteins in ATG. It usually appears a week or two after the drips, often after you have gone home. Joint pain, a rash, fever and tiredness are typical. Steroids are given to prevent and treat it. Call your team if these signs appear, and go to emergency if you have a fever.
Can ATG be repeated if the first course does not work?
Yes, a second course is sometimes given, usually with rabbit ATG if horse ATG was used first. It is often considered alongside a transplant, depending on your age and whether a donor is available. Your haematologist will weigh these together rather than repeating ATG automatically.
Can I live a normal life on ciclosporin?
Many people return to work, study and family life while on ciclosporin. You will need regular blood tests, blood pressure checks and care to avoid infections. Tell every doctor, dentist and pharmacist you see that you take it, because several common medicines change its level in the blood.
Can aplastic anaemia come back after ATG works?
It can. Counts sometimes fall again, often while ciclosporin is being reduced, and restarting it may help. Some people later develop PNH or another marrow condition, which is why long-term blood tests matter. Keep every follow-up appointment even when you feel completely well.
Does CION give ATG treatment?
CION's haematology team, led by Dr. Basudev Pokhrel, reviews your reports, presents your case at a tumour board and helps plan the treatment. Where ATG or a transplant needs a specialised inpatient unit, the team coordinates care with qualified centres. Ask any centre about its isolation rooms, irradiated blood supply and emergency cover.
Is ATG treatment covered by Aarogyasri or insurance?
Treatment for aplastic anaemia is covered under some government schemes and many cashless insurance policies, but the rules differ and change. Aarogyasri, PM-JAY, CGHS, ECHS and EHS each have their own conditions. Check your current cover before admission, and share your card details with the helpline for help checking.
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Dr. Basudev Pokhrel reviews blood counts, transfusion needs and blood disorders, and works with the CION tumour board on blood cancers.
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Sources
- NHS — Aplastic anaemia
- NHLBI — Aplastic anemia
- British Society for Haematology — Guidelines for the diagnosis and management of adult aplastic anaemia
- National Health Mission — National Health Mission
This page is general information, not a prescription. Do not change or stop any treatment based on what you read here. If anything is worrying you, contact your own treating team — or call our helpline and we will help you reach the right specialist.
Keep reading
Related pages
Severity Grading in Aplastic AnaemiaThe grade that shapes whether ATG is offeredEltrombopag in Aplastic AnaemiaThe tablet often added to ATGLiving With Aplastic Anaemia During TreatmentInfection care and daily life on treatmentAplastic Anaemia Treatment Cost in IndiaIndicative costs and what schemes coverAplastic Anaemia and Marrow FailureThe full guide to this condition
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Weighing ATG against a transplant?
Share your marrow report with us. The CION haematology team will go through the options with you and explain what to ask. One helpline serves every CION centre.