Hematology
Clinical discussions on blood disorders, coagulation, transfusion medicine, and hematologic malignancies.
Recent Discussions
Are there data to support full-dose anticoagulation added to an antiplatelet in recurrent peripheral arterial thrombosis requiring revascularization and stenting?
This question comes up frequently at our institution. I previously consulted with our vascular surgery team who referred me to this trial of Edoxaban with SAPT, trying to avert what may be limb loss if the bypass graft/stent fails. We've often promoted rivaroxaban 2.5 mg po BID per VOYAGER PAD if we...
When should you use caplacizumab in the treatment of acute TTP patients?
Whenever I encounter a patient with features of thrombotic microangiopathy and a normal coagulation panel (that rules out DIC), I consider the possibility they may have immune TTP.If my suspicion of immune TTP is high (e.g. history of autoimmune disease, possible relapse of immune TTP) and there is ...
Would you expect a reduced neutrophil count in individuals with a partial duffy null phenotype?
The Duffy null phenotype's impact on neutrophil counts is "all or none". Approximately one-third of patients with the Duffy null phenotype Fy (a-b-) will have a neutrophil count below the usual lower limit of normal. The range of neutrophil counts in individuals with Fy (a+b-) and Fy (a-b+) is exact...
What is your approach to the management of unprovoked distal DVTs?
The management of distal deep vein thrombosis (DVT)—[involving the peroneal, posterior tibial, anterior tibial, or the muscular calf veins (gastrocnemius and soleus); proximal DVT, by contrast, refers to thrombosis in the popliteal, femoral, or iliac veins]—is evolving in step with broader changes i...
How would you approach escalation of therapy in an adult patient with refractory Still’s disease and associated MAS/HLH (ferritin >100,000, transaminitis, DIC) despite high-dose steroids, high-dose anakinra, tocilizumab, and ruxolitinib?
Emapalumab is an appropriate escalation in the described circumstance. I have no experience, and there is little published data as of yet with MAS825, but I would position this as an option to pursue before using etoposide. While there may be an indication of confounding, etoposide use nonetheless h...
What is your approach to IV fluid resuscitation during a sickle cell vaso-occlusive crisis?
My approach to IV fluid resuscitation in vaso-occlusive crisis is cautious and individualized. Adequate hydration is important to prevent further sickling, but I avoid aggressive fluid loading because of the risks of pulmonary edema and acute chest syndrome. I typically use isotonic balanced crystal...
In a pregnant patient with PNH without aplastic anemia who has residual hemolysis while on ravulizumab and on prophylactic LMWH, what else can be done to reduce thrombotic risk and improve maternofetal outcomes?
Personally, I feel that C5 inhibitors are now close to obsolete in the management of PNH, since C3 and factor B inhibitors are more effective and inhibit both intravascular and extravascular hemolysis. Whether or not to use pegcetacoplan or iptacopan depends on the trimester, the seriousness of the ...
How do you manage anticoagulation for patients with DVT/PE who have brain metastases?
Not all brain metastases pose the same risk to patients. Rapid, numerous (even if tiny), new onset metastases from RCC or melanoma (especially BRAF mutant) can go from asymptomatic to life threatening hemorrhage within 1-2 weeks and I would strongly caution anti-coagulation in these patients. If the...
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...
How would you approach anticoagulation for a newly recurrent VTE on progestin-only therapy?
Would you consider this recurrence event hormonally induced and discontinue transdermal progestin, or would you consider this an unprovoked event? I would likely consider this an unprovoked event, as the provoking factor of transdermal progesterone should be extremely weak, if at all. Would you c...