Hematology
Clinical discussions on blood disorders, coagulation, transfusion medicine, and hematologic malignancies.
Recent Discussions
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 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...
When following current COG ALL protocols with the addition of two courses of blinatumomab to treatment for SR and HR patients, how frequently should surveillance bone marrow and MRD evaluations be performed?
With the caveat that I only treat adults, but the general concepts are similar:In our practice, we routinely do bone marrow exams with MRD assessment after the first cycle of blinatumomab. Assuming this shows no detectable disease, we typically will then perform the same before transitioning to main...
Do you use premedications (acetaminophen, diphenhydramine) before pRBC and plt transfusions to prevent febrile nonhemolytic transfusion reactions and allergic reactions?
I do not routinely premedicate patients. There is a recent meta-analysis that shows no benefit. I only premedicate those who have had a prior transfusion reaction. Old studies showed this was a common practice but those studies were performed before universal leukoreduction and other strategies aimi...
Would you offer TPO-RAs to a steroid-refractory chronic ITP patient with history of stroke?
Yes, if needed, though with a bit of trepidation, and it probably wouldn't be my first choice. Second-line chronic ITP treatment can include TPO-RA, rituximab, or splenectomy, and no one treatment is clearly better than the others (Neunert et al., PMID 31794604). Both splenectomy and TPO-RAs have in...
What treatment considerations do you make for elderly patients with relapsed/refractory follicular lymphoma?
Treatment options for R/R FL patients depend not only on the condition of the patient but what was received in 1st line and the duration of that line of therapy. Given that if a patient has received chemo-immunotherapy in the frontline setting and had a prolonged remission (> 5 years), then these ag...