Hematology
Clinical discussions on blood disorders, coagulation, transfusion medicine, and hematologic malignancies.
Recent Discussions
What is your perioperative approach for a patient with severe hemophilia?
The optimal management of people with hemophilia is complex. Planning for elective surgery should include the patient, family/caregivers, and all relevant clinicians to ensure that best practices are followed. Collaboration with experts from a hemophilia treatment center to develop a hemostatically ...
What is your approach to a patient who has an ischemic stroke while on clopidogrel despite strict compliance and normal results on clopidogrel response assay?
Not all recurrent infarcts are from a failure of anti-thrombotics, some patients with large artery atherosclerosis are not taking their statin (as evidenced by no change in LDL-C) or are not exercising (based on subanalysis of SAMMPRIS), other lacunar subtype patients have uncontrolled hypertension,...
Can you use other iron formulations if a patient develops Stevens-Johnson Syndrome with ferumoxytol?
I have never seen it in tens of thousands of doses so it is difficult to answer. If this is actually real, it must be due to CHO component and not Fe (that would be awful). I would use another formulation and premedicate with steroid and H2 blocker before. Do not use antihistamine.
How would you approach immunosuppression for patients with severe aplastic anemia who are not transplant or ATG candidates?
There are relatively few alternatives. One is just supportive care with transfusion, antibiotics, etc. Many patients will adapt to low Hb and do ok with low platelets and do not require therapy. A calcineurin inhibitor alone or with eltrombopag can also be used - the response rate is not as good as ...
Should assessing for a MTHFR mutation be part of the thrombophilia evaluation in a patient presenting with a thrombus?
MTHFR mutation testing is of very little utility, given that the functional readout of MTHFR dysfunction is homocystinuria. The intake of the treatment of homocystinuria is folate, which is ubiquitous in the US diet. Thus, homocysteine levels would be adequate for testing, if such testing is indicat...
What regimen would you recommend for a younger, fit, transplant eligible patient with relapsed IDH1 positive AML?
If there was only one answer! The decision revolves around co-occurring cyto and molecular genetic abnormalities (in addition to IDH1) and the duration of remission in first CR. In general, IDH mutant AML - without other high-risk genetic lesions - is very responsive to all of our treatments whether...
With what agents can you replace PPIs if they cause thrombocytopenia?
The incidence of PPI-induced thrombocytopenia is very low - and really only reported in case reports. I would suggest ensuring the low platelet count is really from the PPI (in some cases may be reasonable to re-challenge the patient), and not from a more common reason. In a recent case report on La...
What would be your preferred second line treatment for a frail elderly patient progressing on Rd?
It will largely depend on the degree of frailty. Many of the myeloma therapeutics are well tolerated, even among older adults or those with comorbidities. Factors such as the time spent coming to clinic or to the infusion center matter as well. It is useful to understand the baseline cytogenetic abn...
Would you offer a complement inhibitor to a minimally symptomatic PNH patient with mild non-transfusion dependent hemolytic anemia?
The context would determine whether this patient should receive complement inhibitor. The first consideration is whether the patient has concurrent aplastic anemia or bone marrow failure. Often, patients with aplastic anemia have a small PNH clone that is not clinically significant and does not caus...
In which platelet function disorders would you consider use of Novoseven as opposed to platelet transfusion?
There are now two recombinant activated factor VII (rFVIIa) available in the US. Trade names are NovoSeven RT and SEVENFACT. NovoSeven RT is US FDA approved for use in Glanzmann thrombasthenia. There are case reports of its efficacy in off label use for other inherited platelet function defects. SEV...