Hematology
Clinical discussions on blood disorders, coagulation, transfusion medicine, and hematologic malignancies.
Recent Discussions
Is there a role for frontline combination therapy with a hypomethylating agent plus venetoclax for high risk MDS?
Yes, if we extrapolate from AML and based on promising phase 1b clinical trial results (link below) so far, but venetoclax is not approved for MDS as of yet. Improved CR but also increased cytopenias, dose has not been confirmed yet. https://www.ashclinicalnews.org/on-location/ash-annual-meeting/ven...
Do you routinely offer a bisphosphonate or denosumab to multiple myeloma patients without skeletal lesions?
Our practice is to give 2 years of bone-directed therapy in all comers. Preferably bisphosphonates over denosumab for cost reasons unless needed due to CKD or intolerance.I agree that the case is less compelling for patients without skeletal lesions at baseline. An old RCT of bisphosphonates versus ...
Would you consider allogeneic stem cell transplant for a newly diagnosed patient with favorable risk AML who had residual disease after initial therapy that included the need for re-induction?
Even though he/she is favorable risk, the fact that he/she required reinduction means biologically aggressive disease and hence increased risk of relapse. So would consider for allo sct. Also was the induction 7+3 or HIDAC induction? Did the patient go into CR after reinduction? What did the NGS sho...
How do you approach the use of low-dose aspirin for primary prevention in non-pregnant patients with SLE and positive aPL antibodies, without clinical criteria for APS?
I personally do not put all asymptomatic SLE patients with aPL labs on low dose aspirin. This is a somewhat controversial topic. Most of the data we have are from observational studies and results are mixed in regards to efficacy of low dose aspirin for primary prevention in this population. SLE pat...
How do you manage testosterone replacement therapy-induced erythrocytosis?
Testosterone is a known risk for thromboembolism. What is not known is whether it is the hematocrit or the testosterone itself that is the trigger for thrombosis. Note also that epidemiologically, the age group that generally is prescribed testosterone also has a high prevalence of thrombosis. My ap...
What clinical factors impact your upfront treatment decisions in transplant-ineligible MM?
My approach is to start with up-front adjustments in choice of drugs, dose, and schedule based upon many factors: age, organ function/other comorbidities, concurrent medications, insurance/other economic factors, personal physical mobility, and access to transportation, patient goals, etc.Myeloma tr...
What is your approach to platelet transfusion in heparin induced thrombocytopenia?
In general, I avoid giving platelets in intensely prothrombotic disorders, except in the circumstance of severe bleeding. Severe thrombocytopenia is uncommon in HIT, though DIC may occur in some patients. However, bleeding is relatively uncommon and platelets not generally necessary.
Do you recommend the use of dexamethasone and anakinra as upfront treatment in a pediatric patient with secondary HLH (nonrheumatic) who is too ill to tolerate etoposide?
If there is no concern for new malignancy or systemic infection, then glucocorticoids are reasonable. I use methylprednisolone up to 30 mg/kg/day (max. one gram). Anakinra is a safe and often effective therapy for secondary HLH. It is quick acting and has a short half-life so I use it early. I gener...
Is there an absolute IgM level, in an asymptomatic patient on surveillance that initiation of therapy would be considered for Waldenstrom's macroglobulinemia?
The rate of progression of a paraprotein in a plasma cell disorder or LPL is always concerning, but it's not enough to bring about action. That said, we clinicians are always looking for bad behavior by cancer cells -- these are the indications for treatment more than the rate of rise or attainment ...
For a patient with MM progressing on a daratumumab-based regimen, is it preferable to entirely switch drug class or is another monoclonal antibody such as isatuximab an acceptable next step?
I recommend switching drug classes after progression on daratumumab.Isatuximab, like daratumumab, is a monoclonal antibody against CD38. It has been shown to be ineffective after progression on daratumumab. Mikhael et al, PMID 33980831. While elotuzumab is a monoclonal antibody with a different targ...