Hematology
Clinical discussions on blood disorders, coagulation, transfusion medicine, and hematologic malignancies.
Recent Discussions
How do you approach treatment of vasculitis in a sickle cell disease patient?
Will highly depend on the vasculitis type and the acuity of the situation. For ANCA vasculitis, approaches based on rituximab and low glucocorticoid doses might be attractive (granted not severe disease, e.g. RPGN, DAH which should require pulse glucocorticoids). For large vessel vasculitis, a si...
Would you routinely use G-CSF prophylaxis in a CMML patient for decitabine-related neutropenia?
I would use G-CSF if the patient is in remission/responding to decitabine and neutropenia, is decitabine induced and not due to CMML. I will not use at diagnosis or when not in remission as neutropenia may be disease-related.
What is the maximum pRBC volume you can transfuse when performing a manual exchange transfusion in an adult-sized patient with sickle cell disease?
It depends on how much hemodynamic stress the patient can tolerate and the rate of the phlebotomy. The rate is usually 30 minutes for every 500 cc whole blood, but may need to slow down in smaller-sized patients (e.g. 50 kg or less), patients with history of pre-syncope or syncope with phlebotomy, a...
How do you approach management of sickle cell patients who mistrust Western medicine and prefer naturopathic therapies?
With compassion and understanding, I would explain that the lifespan of patients with SCD in regions with access to Western medicine far exceeds that where the disease is most prevalent. Controlled clinical trials have proven the utility of hydroxyurea to alter beneficially the course of disease and...
Given results of the ELEVATE-RR study, would you consider use of acalabrutinib in all patients with previously treated CLL, or restrict it to certain patient populations?
Efficacy and safety are both important for evaluating new therapies. The ELEVATE-RR study demonstrated equivalent efficacy with a hazard ratio of 1.0 which indicates response duration was identical. Notably, several indications of safety were better which then would tilt the benefit to using an alte...
In the rare setting of enoxaparin injection-induced abdominal wall hematoma in patients requiring long-term anticoagulation, what is your timeline for restarting anticoagulation?
Abdominal wall hematomas typically occur when a vessel has inadvertently been injured during injection. Timing of resumption of anticoagulant will vary with the underlying indication for anticoagulants. For a high-risk indication, eg multiple cardiac valves in patients with history of stroke, I woul...
What is your approach to CLL in patients with atrial fibrillation and/or on anticoagulation?
Before the availability of venetoclax, the only approved targeted oral therapy for patients with CLL was ibrutinib. Given the lack of alternative options, patients with atrial fibrillation and/or patients on anticoagulation were treated with ibrutinib. Use of anticoagulation with ibrutinib can incre...
Do you find ELEVATE-RR data and study design compelling to start preferentially using acalabrutinib over ibrutinib?
The inferiority design of the ELEVATE-RR included a 1.429 margin, but the hazard ratio between treatments was 1.0 as related to DFS and 0.82 (favoring acalabrutinib) for OS. This improved OS likely is reflective of lower cardiac events and other adverse events. To me, this is sufficiently beneficial...
What is your preferred maintenance strategy for high risk multiple myeloma?
Ok. First off, what is high risk in the setting of maintenance therapy? I define high risk in this area as R-ISS 3 [incl t(14;20)], ≥ 5% circulating PCs, extramedullary disease [except salivary glands], hypodiploidy, or karyotypic t(8;22). We frequently argue about this definition since there is no ...
For frail patients with cardiac co-morbidities and relapsed CLL with high cytogenetic risk, what are some considerations for using continuous acalabrutinib over fixed duration therapies such as venetoclax/rituximab?
Continuous acalabrutinib has relatively low incidence of significant AE and does not require multiple prolonged infusion visits which is very appealing for frail patients. As well, available data would suggest that those with TP53 abnormalities (high genetic risk) do similarly to those without this ...