Hematology
Clinical discussions on blood disorders, coagulation, transfusion medicine, and hematologic malignancies.
Recent Discussions
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...
Under what circumstances would you consider anticoagulation in a young female patient with persistently elevated factor XI activity?
First, get a baseline D-dimer to see how procoagulant she is at that point. If elevated, long travel on plane, pre-op and post-op for 2 months - consider short-term anticoagulation. If past thrombosis - give lifelong anticoagulation. If pregnant - follow D-dimer; if it goes up, anticoagulate.
Should patients with active multiple myeloma and other gammopathies be routinely vaccinated against herpes zoster?
All patients starting anti myeloma therapy should be on acyclovir prophylaxis, typically starting at 400 mg BID but renally adjusted to 400 mg daily if needed. This provides substantial protection against zoster. Patients may get shingrix but given that their immune response to the vaccine may be su...
How often should you repeat iron testing in patients with hemochromatosis, not on phlebotomy?
I can't think of a reason in the world to not do phlebotomy either therapeutically or through donation until TSAT is around 30 and ferritin is <100. I try to keep my hemochromatosis patients low, not high normal because the propensity for high TSATs makes subclinical deposition easy. I don't think t...