Hematology
Clinical discussions on blood disorders, coagulation, transfusion medicine, and hematologic malignancies.
Recent Discussions
What is your approach to iron supplementation in patients with an active infection?
In patients with active infections, I generally avoid intravenous iron due to the potential for promoting pathogen growth, a practice supported by cautions from nephrology and gastroenterology society guidelines. However, evidence for the risk of infection with IV iron is inconsistent, underpowered,...
Do you attempt treatment breaks from bispecific antibody therapy in patients with relapsed myeloma who achieve a sustained MRD-negative complete response?
I don't attempt to stop therapy in people who achieve deep responses and are tolerating the drug, but this is mostly because there is currently a paucity of prospective trials, so the specific time at which stopping therapy is optimal has not been established. I do have a low threshold to space out ...
Following the ECHO trial, are you routinely incorporating acalabrutinib plus bendamustine-rituximab into your frontline treatment approach for patients with MCL?
This is a question with multiple correct answers. I use the following principles in making my decision: BR is an excellent “backbone” induction regimen in any age group. Cytarabine is the main drug in the more aggressive induction regimens used in younger patients. Induction chemotherapy achieves h...
In patients with inflammatory arthritis (RA, psoriatic arthritis) and a history of MGUS are there any concerns regarding use of biologics?
There is no absolute contraindication to any particular biologic used to manage active RA in a patient with MGUS. The literature does point out a small potential risk associated with tocilizumab in terms of development of myeloma influenced by the IL-6 pathway (and I would tend to extend that potent...
What factors do you consider before discharging an MGUS patient from hematology clinic to safely follow with outpatient PCP?
In general, I follow the risk stratification referenced in the Mayo Clinic's recent review, and I tend to think about a clinic discharge from hematology if they have low-risk MGUS, i.e., serum M protein <1.5 gm/dL, IgG subtype, normal FLC ratio (0.26-1.65).I then use the Lee Index to estimate the pa...
Are there any alternative, hypofractionated RT courses for patients with DLBCL that can be used during the COVID-19 pandemic?
ILROG recently came out with guidelines pasted below: Synopsis of ILROG Recommendations for Administering Radiotherapy for Hematological Malignancies During Emergency Conditions of the COVID-19 Pandemic • We are facing an increased demand for RT to substitute or complement systemic therapy deemed i...
Do you consider co-prescribing hormone therapy and anticoagulation in a patient with prior DVT and uncontrollable VSM uncontrolled by non-hormonal therapies?
While I agree that you need to be thoughtful about adding additional VTE risk to patients with a history of VTE, I am much less concerned when patients are already on full-dose anticoagulation. Especially when the medication is transdermal estrogen, which has the lowest effect on thrombotic risk. I ...
How would you manage a patient with HbSS and severe pulmonary hypertension on home oxygen?
This patient should be referred to a specialist in pulmonary hypertension in sickle cell disease for right heart catheterization and aggressive management of the pulmonary hypertension. As described, the patient is not a good candidate for lung transplant or gene therapy.
Do you use particular cutoffs of troponin and BNP that you deem indicative of a hemodynamically significant/high-risk PE, or do you see any abnormal value as indicative?
Biomarkers are contributory variables in a multivariable assessment of any patient with pulmonary embolism. In light of the multiple factors that influence biomarker levels in a given patient, it is challenging to define one-size-fits-all cut points for meaning. It is also important to recognize tha...
How would you manage symptomatic, bilateral subsegmental PE developed after long air travel?
I generally consider air travel to be a relatively weak provoking factor. Although the 2020 ASH guidelines do not address this, the ASH Guidelines from 2018 on management of VTE cite a 2.8-fold increased risk for VTE associated with air travel, which is roughly similar to the increased risk associat...