Hematology
Clinical discussions on blood disorders, coagulation, transfusion medicine, and hematologic malignancies.
Recent Discussions
In what scenarios do you use a chromogenic factor X assay in adjusting INR goals for patients on warfarin?
I do not use this method. It has been suggested that such assays be used in patients with lupus-type inhibitors who have significantly prolonged prothrombin times at baseline. In this setting, if the INR is "therapeutic," one would confirm an adequate warfarin effect if the factor X activity was in ...
Would you consider using transdermal estrogen in a patient with “high risk” APLS patient on warfarin?
Given her clinical diagnosis of high-risk APS, I would first trial nonhormonal therapies or progesterone-only therapies for management of her post-menopausal symptoms. Current ACR guidance recommends against hormone replacement therapy in patients with APS on anticoagulation (Sammaritano et al., PMI...
Would you use routine PET scans after two cycles of R-CHOP to guide first-line treatment de-escalation in low-risk (aaIPI = 0) DLBCL patients?
This phase III trial suggests that in very low-risk limited-stage DLBCL (aaIPI = 0), patients who achieve a negative PET after two cycles of R-CHOP can safely receive only four total cycles instead of six, with similar 3-year PFS (92% vs 89%) and less toxicity. However, the results apply to a highly...
How do you approach relapsed idiopathic HLH?
If the patient was previously in remission after etoposide and steroids, they may well respond to etoposide and steroids again. I strongly consider hematopoietic stem cell transplant in anyone who relapses after an episode of HLH, since it is usually a harbinger of recurrent and potentially life-thr...
Do you initiate anticoagulation prophylaxis for pediatric patients with vascular compression secondary to solid tumor/lymphoma?
It is an interesting question, but lacks critical details. Of course, most cancers are prothrombotic, and anticoagulation can have risks: Is it arterial or venous compression? Complete obstruction? Acute or chronic? Collaterals? Is it compromising an organ? Is thrombus seen, or is there blood flow?...
Prior to gender affirming surgery, do you hold estrogen (or convert to transdermal) to minimize postoperative VTE risk?
I'd divide this into 2 sub-questions: what to do in a patient who has a history of thrombosis, and what to do in a patient without a history of thrombosis. In a patient with prior thrombosis, I would generally have them on indefinite anticoagulation alongside ongoing estrogen use. We know that trans...
Would you consider restarting IMID therapy in a patient with recent stroke while on IMID?
This is a very good question, and practice likely differs across institutions as data is limited. The discussion below refers primarily to the immunomodulatory (IMID) agents lenalidomide and pomalidomide.As you are aware, IMID therapy is known to be associated with an increased risk for venous throm...
How do you approach ADT in patients with high-risk prostate cancer who have risk factors for VTE, such as Factor V Leiden?
My default recommendation for patients with localized, high-risk prostate cancer is to recommend the use of long-term ADT. This intervention seems to offer a relatively large, clinically significant OS benefit for patients in the modern era receiving dose-escalated ADT. This benefit has been observe...
Do you utilize D-dimer to inform anticoagulation duration in the treatment of VTE?
I had developed a policy during my last eight or ten years of practice evaluating how long patients should be treated after a thrombosis and I'd like to share some impressions over these years as well as conclusions that I reached. These conclusions formed the basis of my approach to this problem. I...
Do you routinely stop ESA when starting myelofibrosis patients on JAK inhibitor therapy?
The management of myelofibrosis with anemia is becoming increasingly nuanced, given the several JAK inhibitors available to us and the potential for add-on therapies! An excellent resource to consider regarding decision-making is Jain et al., PMID 39808793. Regarding this specific question at hand, ...