Hematology
Clinical discussions on blood disorders, coagulation, transfusion medicine, and hematologic malignancies.
Recent Discussions
When do you consider iron chelation in elderly patients with transfusion-dependent MDS?
When the ferritin is >1500 or if LFTs due to iron are abnormal between 1250-1500. You have to be careful with chelation at lower levels due to chelation of other micronutrient heavy metals.
Would you initiate chemoimmunotherapy (e.g. RCHOP) in a symptomatic patient with DLBCL who tested positive for COVID19?
It will depend on if he is symptomatic from covid infection or just positive but asymptomatic. If asymptomatic from covid, I would treat. DLBCL is the one which is symptomatic and active disease without treatment is equally immunosuppressive. I would suggest giving rituximab with cycle 2 rather than...
Would you ever consider prophylactic anticoagulation in patients with CKD requiring ESA therapy?
I would not start anticoagulation in this setting solely because the patient is to receive ESA treatment, but would advocate for adjusting the ESA dose to maintain a hemoglobin of 9-10 g/dL, since a number of studies suggest that targeting higher hemoglobin levels is associated with increased risk o...
How do you approach therapy for a fit adult with relapsed AML with CNS involvement after allogeneic stem cell transplantation?
Agree with Dr. @Dr. First Last. If on immunosuppression, would stop immunosuppression. HIDAC q12 hours x 5-6 days reinduction is a regimen that can be used for relapsed AML. There is some data in adding venetoclax to chemo induction and should be considered.If starting venetoclax single agent to add...
How do you choose your systemic treatment for primary mediastinal grey zone lymphomas?
Most of the literature (although not prospective) supports treating with an R-CHOP/EPOCH vs. traditional ABVD. As such, I tend to treat with R-DA-EPOCH. When I have had the unfortunate case of a relapsed/refractory patient, I have tended to treat with some of the newer HL salvage regimens.
How do you counsel patients on JAK inhibitors about the risk of venous thromboembolism, MACE, and cancer?
I advise patients that there remain many unanswered questions regarding these side effects that will be resolved with longer term use with these agents. Shared decision-making is critical for these discussions. Data available from current extensions of clinical trials for JAKi, additional risk facto...
What would be the ideal patient to receive selinexor-based therapy over other options for penta-refractory multiple myeloma?
Selinexor makes sense in combination with a partner, usually, either Carfilzomib or Pomalidomide, after patients are refractory to RVd --> Dara-Pd --> KPd --> Belantamab. An alternate route might be Dara-Rd --> KPd or PVd --> Bela. In essence, Selinexor is what I use when there's nothing left standa...
In a patient with breakthrough VTE on rivaroxaban, would you switch to apixaban or an agent with a different mechanism of action?
A complex situation and a lot will depend on the clinical circumstances e.g., compliance, type of failure, etc. I would still consider apixaban. However, if the failure was a more serious event, consider alternative anticoagulants.
What workup do you perform to evaluate for underlying triggers/associated conditions in a pediatric patient with autoimmune hemolytic anemia?
The diagnostic workup that I would recommend in order to rule out a possible underlying condition includes the following: Extensive red blood cell typing in anticipation of possible transfusion. Further immune-haematological investigations: C3, C4, CH50 Auto-antibodies (ANA, anti DNA), antiphosp...
How would you manage an incidental catheter-related thrombosis in a functioning dialysis catheter?
If the patient is asymptomatic and the catheter is functioning well, I recommend starting anticoagulation.If the patient develops symptoms, he or she should still be anticoagulated but the catheter removed. Anticoagulation options in ESRD patients include Coumadin, Eliquis (my preference is a dose o...