Hematology
Clinical discussions on blood disorders, coagulation, transfusion medicine, and hematologic malignancies.
Recent Discussions
Is obinutuzumab obligatory with AV combination for patients with unmutated IGHV?
Obinutuzumab certainly improves PFS and TTNT but it's important to recall that the OS (in the non-COVID-19 adjusted data) was inferior with AVO in the full cohort. I will certainly discuss adding obinutuzumab for patients with unmutated IgHV with all patients, but will recommend it only for patients...
In which patients with essential thrombocythemia would you use ropeginterferon alfa-2b?
Currently, the FDA's only indication for Besremi (ropeginterferon) is polycythemia vera (PV). I am not sure why this is since there is ample data on treating essential thrombocytosis (ET) patients with pegylated interferon. So, if still available, my answer covers the use of either. It also covers E...
What is your preferred strategy for young adults with ITP complicated by recurrent autoimmune neutropenia?
This is a great question, and I'll say that AIN can be particularly difficult to treat! I'd first ask how low the ANC is and if the patient is presenting with frequent infections/hospitalizations. If not, there may not be a need to treat the AIN (we may just be treating ourselves); oftentimes, there...
How would you approach hormone replacement therapy for perimenopause in a patient with increased risk factors for VTE?
Like many medical choices, this decision involves weighing trade-offs—specifically, the risk of venous thromboembolism (VTE) versus the burden of severe menopausal symptoms. If we focus only on VTE risk (and set aside the trade-offs related to menopausal symptoms and the controversial issue of breas...
How do you approach laboratory assessment for anticoagulation adherence when working up anticoagulation failure?
When faced with an anticoagulation failure, my go-to test for adherence is looking at the medication-dispense report (if you have this available at your institution, it is very handy for understanding the patient's adherence to anticoagulation). Typically, this will either show intermittent dispensi...
How long would you anticoagulate for a catheter associated DVT in pregnancy?
Available guidelines for management of catheter-related DVT, including the 2012 ACCP CHEST guidelines, typically recommend 3 months of anticoagulation if the central venous catheter (CVC) is removed. In those who require ongoing CVC placement, which is common in patients with cancer requiring system...
How often do you check weight and adjust anticoagulation dosing in pregnancy?
In patients on prophylactic or intermediate doses of Lovenox (e.g., 1 mg/kg once daily), I do not adjust the dose during pregnancy. (Although this "intermediate-dose" approach is not supported by the Highlow trial, I will use 1 mg/kg daily in a woman with a more extensive clotting history—such as a ...
For patients with intermediate or lower risk essential thrombocythemia with plt >1000 but no symptoms, do you favor aspirin only therapy or aspirin and cytoreduction?
First, the wrong question is being asked. The correct question is, what is the proof that the low-risk, intermediate-risk, or high-risk ET classification has any validity? My answer would be that this classification has no validity. Whether it is based on the IPSET scoring system or one of the other...
Do you consider thrombocytopenia a contraindication for fibrinolytic therapy for a massive PE?
If one has access to mechanical thrombectomy devices and operators, they should be considered before systemic thrombolytics unless the massive PE is causing imminent danger to the patient/patient is going to code/die, in which case the risk of dying from said PE is higher than potential bleeding eve...
What is your target Hgb/Hct for women who are pregnant and have sickle cell disease in whom you are doing scheduled transfusions?
Hg 10-11. My main goal is to suppress reticulocytosis and therefore, the production of more sickled cells.