Hematology
Clinical discussions on blood disorders, coagulation, transfusion medicine, and hematologic malignancies.
Recent Discussions
What radiation dose do you typically use for relapsed DLBCL following 6 cycles of R-CHOP?
There are several potential scenarios, all with different answers, so I will illustrate a few.Historically, second-line chemotherapy (e.g., R-ICE) would first be pursued for relapsed DLBCL, and if the disease was still responsive to chemotherapy (CR or PR), then the patient would proceed with high-d...
How do you modify HMA treatments for a patient with high-risk MDS experiencing prolonged cytopenias after each cycle?
When using azacitidine for the treatment of MDS, I adjust the dose in case of cytopenia for cycle 2 onwards. If there was no baseline cytopenia (ANC >1.5, PLT >75K) but cytopenia developed with treatment, the subsequent cycle is delayed until counts recover, and the dose is based on the nadir and t...
What is your approach to optimizing pre-operative hemoglobin in patients with sickle cell disease?
This is always a question that has to be hyper-individualized. The research, and therefore the associated professional guidance, is thin. The American Society of Hematology (ASH) 2020 Guidelines for Sickle Cell Disease: Transfusion Support and the NHLBI Expert Panel Report (2014) are the only profes...
Do you consider co-prescribing hormone therapy and anticoagulation in a patient with prior DVT and uncontrollable VSM uncontrolled by non-hormonal therapies?
While I agree that you need to be thoughtful about adding additional VTE risk to patients with a history of VTE, I am much less concerned when patients are already on full-dose anticoagulation. Especially when the medication is transdermal estrogen, which has the lowest effect on thrombotic risk. I ...
For low/intermediate essential thrombocythemia not on cytoreduction, would you temporarily cytoreduce in anticipation of surgery?
First, I am going to answer this question with a question. What is low/intermediate essential thrombocytosis (ET)? I ask this question because we are living in the 21st century in the midst of the genomic era, and it is far past the time that we should be dwelling on phenotype instead of employing p...
In your practice, what premedications do you use for subcutaneous daratumumab?
We administer the following pre-infusion medications 1 hour to 3 hours before the first 4 SQ infusions, and then we drop all premedications (except for dexamethasone) thereafter: Dexamethasone 20-40 mg Acetaminophen 650 mg Diphenhydramine 25 mg Montelukast 10 mg [this is not in the package insert b...
Do you continue daratumumab beyond 24 months in first line treatment of amyloidosis?
This is an important and common clinical question, and one for which prospective data are currently limited. For background, the ANDROMEDA clinical trial (Kastritis et al., PMID 34192431) demonstrated that the addition of daratumumab to cyclophosphamide, bortezomib, and dexamethasone (CyBorD) signif...
What is your approach to iron deficiency anemia after a negative EGD and colonoscopy?
If there is no sign of atrophic gastritis and repeated fecal tests for blood are negative, I’d look first for celiac disease. If all the celiac screening tests rule it out, then I might team up with a hematologist to look for rare birds like transferrin deficiency. I’d probably ease back on PPIs if ...
Would you consider upfront, time-limited anti-IL-5 therapy for I-HES or L-HES to avoid steroid side effects?
There are two parts to this question: Are there better options than steroids for the treatment of iHES and L-HES? The answer is an emphatic yes. These are chronic diseases, and steroids are really not the optimal therapy. IL-5 inhibitors such as mepolizumab and benralizumab are effective in reducing...
If a pregnant patient with a mechanical heart valve takes warfarin throughout her pregnancy, what are the chances that the fetus will be harmed?
Warfarin is effective for thromboembolic prevention in pregnant patients with mechanical valves. There is however an overwhelming evidence that warfarin taken during pregnancy is deleterious to the fetus. Its use during the first 6–12 weeks of gestation can be associated with important fetal complic...