Hematology
Clinical discussions on blood disorders, coagulation, transfusion medicine, and hematologic malignancies.
Recent Discussions
In antiphospholipid syndrome with recurrent strokes, would you consider adding antiplatelets to warfarin?
I agree with Dr. @Dr. First Last. I have had patients with APS and recurrent thromboembolic events although not necessarily strokes to whom I have added aspirin and HCQ to the treatment regimen. I did this because she continued to have recurrent events. However, there is at least one article that ne...
How long would you consider the use of low-dose aspirin in a patient with SLE and high risk aPL profile (without a clinical event)?
I recommend low-dose aspirin (ASA) plus hydroxychloroquine (HCQ) to ALL my systemic lupus (SLE) patients unless they have risk factors for bleeding.I do this based upon the 2017 Italian study by Fasano et al. I explain to my patients that there are uncertainties to this recommendation and that furth...
What is the recommended management approach in regard to diagnostic evaluation and treatment for patients with homocystinuria and cerebral thrombosis?
I think it’s reasonable to start anticoagulants for 3 to 6 months after getting complete blood test panels for hypercoagulation states. Be careful while interpreting abnormal hypercoagulation test results since many times you may see abnormalities. I would also repeat them within 3 months when the p...
In a patient identified as having APLS because of recurrent pregnancy loss without history of thrombosis, but now has a new DVT/PE during pregnancy despite use of enoxaparin—for how long would you recommend anticoagulation?
First, as far as I know, enoxaparin has not been proven to prevent pregnancy loss in obstetric APS. Second, we know that enoxaparin has not been shown to be as effective as heparin in preventing thrombotic events in APS. Third, the patient is pregnant, a thrombophilic state, separate from APS. All t...
In patients with severe hemophilia A on emicizumab for prophylaxis, in case of noncompliance leading to a lapse of more than 2-3 months off therapy, do you reload with emicizumab?
In general, you need to restart the four-week loading then follow with maintenance. First, you need to find out why they were noncompliant (e.g. did not like/could not do subcutaneous injections, did not work, always noncompliant). If they are planning to continue noncompliance, this is not a good ...
How would you approach an early stage II unfavorable Hodgkins lymphoma following 6 cycles ABVD with persistent Deauville 5 with negative biopsy?
This is an active disease and should be treated accordingly. I would not wait. RT is certainly option number one now, but the patient has a considerable risk for recurrence even after RT, since he/she has Hodgkin‘s that is not responding adequately to treatment. Continuing with ABVD in a patient who...
How would you approach a bulky 9 cm DLBCL of the axilla following an excisional biopsy to negative margins?
This is a valid question that is encountered with some regularity in clinical practice. It has also been reported in clinical trials. For example, in the landmark SWOG study, 29% of patients had all gross disease resected at the time of diagnostic biopsy. This was in the pre PET-CT era. In the more ...
Do you hold IV iron in the setting of active infection?
While there is no evidence of harm, there is enough conjecture about the danger to make it prudent to wait until infection is controlled. So yes, I do. Further because of the iron restricted erythropoiesis during infection, the efficacy is likely to be blunted.
What recommendations do you have for a transgender female patient with history of prothrombin gene mutation who is interested in starting gender affirming hormone therapy?
A review of the literature suggests that the risk of VTE associated with hormone therapy in this setting is quite low, even in the presence of other risk factors for clotting (see, for example, Mullins et al., PMID 33753543). Furthermore, the presence of an asymptomatic prothrombotic genotype is rar...
Do you consider discontinuing maintenance therapy in transplant-ineligible patients with Multiple Myeloma?
In absence of side-effects or relapse/progression, I continue maintenance in a dose-attenuated fashion for TI-NDMM based on available evidence in literature. I do encourage patients with standard risk disease to participate in trials asking the MRD-driven duration of maintenance question.