Hematology
Clinical discussions on blood disorders, coagulation, transfusion medicine, and hematologic malignancies.
Recent Discussions
How do you approach a patient with IgM monoclonal gammopathy associated with severe neuropathy of unclear etiology?
I usually confirm if the patient does not have AL Amyloidosis or POEMS, and as part of work up for IgM MGUS, I order MYD 88 mutation. If all are negative and I still believe that neuropathy is caused from his/her MGUS, you can try IVIG for the neuropathy as a trial (of course after using gabapentin,...
In your practice, would you consider the all-oral option of decitabine-cedazuridine + venetoclax for an elderly, unfit AML patient, based on the ASCERTAIN-V trial results?
I see the combination of oral decitabine-cedazuridine (ASTX727) + venetoclax as largely being an appropriate option for any patient with newly diagnosed AML that would be otherwise considered for azacitidine + venetoclax. The inclusion criteria for ASCERTAIN-V (Roboz et al., PMID 42235013) and VIALE...
Do you use anti-microbial prophylaxis when you prescribe ibrutinib?
Traditionally, H.Zoster and PJP prophylaxis was more routinely administered in CLL patients receiving chemoimmunotherapy as these regimens were typically more myelosuppressive as well as immunosuppressive. In the era of the novel BCR receptor agents with the approval of ibrutinib and idelalisib and ...
How do you manage persistent cytopenias in patients with AML who achieve a complete remission with incomplete count recovery after venetoclax and HMA?
This is an important question. How to manage cytopenias on HMA + venetoclax-based regimens is one of the biggest conundrums in the management of AML. The clinical trials to date have not uniformly answered this question based on level 1 evidence. These recommendations are mainly based on anecdotal d...
Do you routinely stop ESA when starting myelofibrosis patients on JAK inhibitor therapy?
The management of myelofibrosis with anemia is becoming increasingly nuanced, given the several JAK inhibitors available to us and the potential for add-on therapies! An excellent resource to consider regarding decision-making is Jain et al., PMID 39808793. Regarding this specific question at hand, ...
Do you use lenalidomide for patients with MDS with 5q- without other cytogenetic abnormalities but with one or more mutations on NGS?
For patients who meet the definition of del(5q) syndrome, I typically utilize lenalidomide regardless of the molecular features of the disease. The original publication (List et al., PMID 15703420), the phase III MDS-004 study (Fenaux et al., PMID 21753188), and the phase III SintraREV study (Díez-C...
How do you decide between anticoagulation and observation for an incidentally detected subsegmental pulmonary embolism in elderly patients with a history of gastrointestinal bleeding?
We face this conundrum not infrequently because subsegmental emboli are subject to high inter-reader variability, and the accuracy of the finding in isolation is suspect (Batayneh et al., Blood 2023). I once mentioned this to a radiologist who reads CTAs and was told, tactfully, that I was full of i...
In a patient with negative Hep B surface Ag, Hep B surface antibody+, and Hep B core antibody+ serologies, do you initiate antiviral prophylaxis (e.g. entecavir) prior to starting rituximab?
I would use entecavir for Hep B reactivation prophylaxis in this case - based on recommendations from AGA 2025 guidelines, which does classify b-cell depleting agents as higher risk for reactivation for both Hep B surface Ag-positive and Hep B surface Antigen neg/core positive patients. It should be...
How do you approach DOAC dose reduction for secondary prophylaxis of VTE in cancer-associated thrombosis?
Data from the API-CAT trial (Mahé et al., PMID 40162636) show that de-escalation of apixaban after 6 months was non-inferior compared to the standard dose with respect to recurrent VTE. Although there was no difference in major bleeding, the lower dose of apixaban was superior from the clinically re...
What is your approach to a situation where DILI is suspected secondary to an important medication (e.g., anticoagulation, antibiotics, etc.), but the diagnosis is uncertain and the liver injury is relatively mild?
If the drug suspected to induce liver injury causes symptoms and ALT is >3 times the upper limit of normal (ULN), I would stop the drug and find an alternative. Even if no symptoms are present, I would stop if ALT is >5 times ULN. Any level increase of ALT below the above parameters would still requ...