Hematology
Clinical discussions on blood disorders, coagulation, transfusion medicine, and hematologic malignancies.
Recent Discussions
How would you manage OCPs in a patient who develops a VTE while on treatment?
If a patient has a venous thromboembolic event, while on a combined estrogen-progesterone oral contraceptive, it is reasonable to continue the OCP with the initiation of anticoagulation. A study from 2016 revealed that it was safe to continue hormone therapy with the anticoagulation (Martinelli et a...
What are your thoughts on adding mycophenolate to steroids in the first line treatment of ITP based on the results of the FLIGHT trial?
This was an impressive study that should alter how upfront ITP is managed. The study was well designed, with randomization against the current standard of care. Efficacy was clear with HR for treatment failure of 0.37 (p=0.0029). What is also nice is that unlike TPO agonists which do not have define...
How would you manage a patient with JAK2-positive PV who is not responding to hydroxyurea or IFN-alpha for cytoreduction?
I would first evaluate for secondary von Willebrand. Continue ruxolitinib, and try to maximize dose. If HGB well controlled and platelets continue to increase, I would check iron, and replace it gently to see if that would help the platelets. If that isn’t possible, or replacing iron doesn't help pl...
How do you counsel male-to-female transgender patients on the VTE risk of hormonal therapy?
Overall, there are minimal data in pediatric populations, but the data from adult populations suggests that in the vast majority of cases, it is safe from a VTE standpoint to administer estrogen therapy in male-to-female transgender patients. The current formulations of estrogen that are recommende...
How would you manage a patient with type 1 cryoglobulinemia secondary to MGUS?
Rituxan can be tried if IgM type MGUS. Please find the attached ASH article on How I treat cryoglobulinemia by Muchtar, Magen, and Gertz; PMID 27799164.
How soon after a VTE would you feel comfortable with a patient undergoing an elective surgery?
Here is my approach: Many factors play a role in decision making such as type of venous thromboembolic event, clot burden, provoked versus unprovoked nature of the event, patient's bleeding and clotting phenotype, associated risk factor such as cancer, etc, type of anticipated surgery, and risk for ...
Would you add chemotherapy to a TKI in treating an elderly patient with de novo CML blast crisis?
Treating CML blast crisis is challenging in any patient and there is no standard of care. Generally, it is recommended to treat with both chemotherapy and a TKI. However, it is most important to adjust treatment to the patient. If a patient is frail and unable to tolerate chemotherapy, I don't think...
When would you consider splenectomy or other immunosuppressive/cytotoxic therapy for steroid-refractory warm autoimmune hemolytic anemia?
If it is refractory to prednisone, my next approach is Rituxan. If it fails to respond to Rituxan, I have had luck with Daratumumab. I avoid splenectomy since the response rate is no better than 30%.
What are your indications for pursuing a rheumatologic workup in a pediatric patient with ITP?
In regard to pediatric ITP patients and a rheumatologic workup, first, there is no data comparing pediatric ITP patients of all ages and both genders as to the exact rates of positivity and the implications of the positivity in any group. Having said that, there is some consensus that adolescent fem...
How would you manage a patient with Stage IVB DLBCL with refractory disease in the retroperitoneum and spleen after 6 cycles of RCHOP?
The management of primary refractory stage IV DLBCL is complex and generally not successful. See NCCN Guidelines for details. I would distinguish, however, between those patients who are clinically refractory and those who have clinically responded well but may have residual disease by imaging, i.e....