Hematology
Clinical discussions on blood disorders, coagulation, transfusion medicine, and hematologic malignancies.
Recent Discussions
How would you approach management of bleeding risk and factor VIII replacement in a patient with severe hemophilia A undergoing stem cell transplant?
Same way as anyone with severe hemophilia: Prophy with QOD factor or weekly hemlibra Extra correction for procedures, trauma, or bleeding
How would you treat a patient with chronic phase CML who could not tolerate nilotinib due to G4 thrombocytopenia despite sequential dose reductions?
It depends on various other factors such as the current response and the doses used. I generally work on trying to get the patients to tolerate treatment first and then focus on response. I have used doses of nilotinib as low as 50 mg daily in some patients; this may make the thrombocytopenia more m...
What are your top takeaways from ASH 2022?
1. Late Breaking Abstract (LBA-1): Consolidation Therapy with Blinatumomab Improves Overall Survival in Newly Diagnosed Adult Patients with B-Lineage Acute Lymphoblastic Leukemia in Measurable Residual Disease Negative Remission: Results from the ECOG-ACRIN E1910 Randomized Phase III National Cooper...
Is there any role in continuing apixaban in a patient with occlusion of the right internal jugular vein with chronic postthrombotic change to prevent a recurrent DVT?
Yes
How do you approach low to moderate titer of APLS when working up unprovoked DVT if it is persistent on repeat testing?
I have a low threshold to recommend long term (indefinite) anticoagulation for unprovoked thrombosis, regardless of whether there is positive APLS testing. I do agree with Dr. @Dr. First Last, however, that shared decision-making is important when committing a patient to prolonged anticoagulation, a...
Do you anticipate a paradigm shift in first line treatment of multiple myeloma from RVD to immune therapy with CAR-T/bispecifics?
A great question that is no doubt being discussed not just by doctors & patients but also by investors, insurance companies, and more. It is certainly possible to shift paradigms in myeloma - I'd even argue, for example, that the induction strategy at most US centers now is Dara-VRd and not VRd as p...
How would you approach a patient with low grade follicular lymphoma (stage IE) of the breast who presents with local recurrence 1 year s/p lumpectomy?
I would re-stage the patient with imaging. If the disease remains localized, then I would treat with definitive RT (24-30 Gy in 2 Gy fractions using ISRT principles). It would be interesting to look back at the pathology from the original lumpectomy. Unless margins were widely negative, I would prob...
Are there any possible scenarios where you would do phlebotomies for heterozygous hemochromatosis?
The answer is yes but unusual. Occasionally, a heterozygote or double heterozygote will be weakly phenotypically positive. If the ferritin and TSAT (on overnight fasting sample) are high, I will. I prefer that blood donation be used but if not an option, I will take it. The iron parameters must be...
How do you approach the workup for a patient with persistently elevated inflammatory markers (CRP and ESR) whose history and exam do not point to a clear cause?
Our hematologist/oncologist referred just such a patient. No evidence of malignancy, but elevated CRP &ESR. I did an “internist’s” workup as I would for dermatomyositis, starting with the most important and therefore most thorough aspect: taking a full and very “invasive” history, followed by a comp...
What is the treatment approach if an AML patient receiving azacitidine/venetoclax is later found to have FLT3 and IDH2 mutations?
This is solely an opinion as there is little data. Since FLT3 inhibitors are not approved for use with azacitidine and venetoclax and data is just emerging about triplet therapy with the addition of these inhibitors, I would just keep going with azacitidine and venetoclax and reserve FLT3 and IDH2 i...