Hematology
Clinical discussions on blood disorders, coagulation, transfusion medicine, and hematologic malignancies.
Recent Discussions
In a patient with a bleeding disorder, how would one approach anticoagulation during active COVID infection?
This is very dependent on what the bleeding disorder is, how severe it is, and what you think is the risk of clotting with this COVID infection in this individual. For example, if this is a mild-moderate type I VWD with very infrequent bleeding with a need for treatment, you could probably handle th...
In someone with an asymptomatic JAK2 V617 mutated and BCR/ABL negative MPN with a steadily rising WBC, when do you decide to start cytoreductive therapy and which agent(s) do you recommend?
First, let's abandon the phase "BCR/ABL-negative MPN". This is an oxymoron because BCR/ABL can be expressed in a JAK2 driver mutation-positive MPN. In fact, both BCR/ABL and JAK2 mutations can be expressed in normal individuals at very low levels without causing disease. Both mutations can also be p...
Is rituximab for refractory ITP contraindicated in the setting of an active COVID infection, particularly in a patient with asymptomatic COVID?
Given that we would delay rituximab treatment for many active infections, I would recommend that we apply the same restrictions. I would hold the rituximab for ten days after covid test confirmation.
Would you consider anifrolumab in the management of hematologic manifestations in SLE?
Hematologic manifestations in SLE vary widely from asymptomatic to life-threatening, from cytopenias to severe bleeding to thrombosis to multiorgan failure. Hematologic manifestations can also be compounded by medications, infections, and co-existing conditions. Each of these manifestations is drive...
What is your preferred first line regimen for myeloma with severe renal impairment, either on or off dialysis?
In general, for patients with renal insufficiency related to their myeloma, time is nephrons. So the earlier you can correct the hypercalcemia, lower circulating uric acid, stop ongoing bad behaviors (NSAID overuse, etc), and treat the myeloma, the better. If the patient is admitted, I will give pa...
Which, if any, young/fit intermediate-risk AML patients would you not offer allogeneic transplant to in MRD- CR1?
At our center, we routinely offer the option of allogeneic stem cell transplant to younger fit patients with intermediate and poor risk AML. The only individuals that we would not offer this to are those with biallelic CEBPalpha mutant AML or NPM1 mutant/FLT3 wildtype AML without a matched sibling d...
Are there any differences in your approach to therapy for secondary versus primary myelofibrosis?
Good question. I will risk stratify patients with secondary MF using the MYSEC-PM score and primary MF patients using DIPSS+ or MIPSS. Anecdotally, patients with secondary MF tend to have more indolent MF and there is definitely a grey zone period when you know they are transforming but still doing ...
How soon do you anticipate response to cyclosporine in red cell aplasia and what cyclosporine trough levels do you target?
I typically use tacrolimus rather than cyclosporine. I find it has fewer off target effects and is easier to maintain blood levels. Trough blood level is 5-10. Cyclosporine levels are 100-400 which is too broad. I would give it at least 3 months. If not done already, I would do for LGL.
What is your approach to using medications that can cause bone marrow suppression in SLE patients who have persistent leukopenia?
I am so glad someone asked this question. I have heard some peers state that they are reluctant to use immunosuppressants in this situation. However, I do not agree with this. The whole reason our systemic lupus (SLE) patients have leukopenias is due to their autoimmunity (but make sure drugs, infe...
How do you approach anticoagulation in the setting of HIT and thrombocytopenia?
This is a very relevant but rather broad question. On a day-to-day basis, the decision on whether one is dealing with HIT vs other causes of thrombocytopenia can be complex. Applying the 4Ts score is easier in retrospect, but in real life patient management, the score has the potential to change alm...