Hematology
Clinical discussions on blood disorders, coagulation, transfusion medicine, and hematologic malignancies.
Recent Discussions
In a patient with history of recurrent VTE despite anticoagulation, would you consider lenalidomide as part of your initial myeloma regimen?
I would still consider lenalidomide as part of the initial myeloma regimen provided that they were on therapeutic dose anticoagulation (my preference is apixaban 5 mg BID or rivaroxaban 20 mg daily). Ideally, this would be started at least 3 months after therapeutic dose anticoagulation for the most...
How do you decide when, if ever, to defer pharmacologic venous thromboembolism prophylaxis for hospitalized patients?
For the majority of patients who are not actively bleeding, I use pharmacological prophylaxis. I prefer heparin products, unless they have a history of HIT or religious preferences on porcine products. Even for patients planned for surgery, heparin can always be held or reversed. I prefer LMWH over ...
What could explain discordant iron studies?
This is an incredibly common question, largely generated by the zeal to use the serum ferritin and failure to appreciate the need for an overnight fast when ordering the TSAT (the ferritin does not require fasting). The most common culprit in this situation is iron containing vitamins. Prenatal vita...
At this time, how are you using MRD testing for clinical management of patients with multiple myeloma?
Off a clinical protocol, I only routinely use MRD (clonoSEQ) in a very specific setting. That setting is low risk patients who have received autologous transplant as part of first line therapy and did well. Specifically, if the patient's response to first line therapy is VGPR or better at day+60, th...
In which cases would you consider early transition to DOAC (within 72 hours) for hospitalized patients with intermediate or high risk PE?
Two DOACs are FDA-approved for early use (within 72 hrs), rivaroxaban and apixaban. The PEITHO-2 dabigatran cohort study included no comparison group (its authors called it a "trial"?) and required "72 hrs" parenteral anticoagulant before dabigatran but the small print in its Lancet Haematology show...
Given the improved ability to spare heart, kidney and liver, should IMRT be the standard of care for gastric MALT lymphoma (despite the low dose needed to effectively treat these patients)?
Gastric MALT lymphoma is a tantalizing disease to utilize IMRT. The target is typically irregularly shaped and surrounded by critical normal structures, including the heart, liver, and kidneys. The standard dose for gastric MALT lymphoma is 30 Gy. Thus, one needs to be mindful of dose to all of thes...
For essential thrombocythemia with an indication for aspirin, would you defer therapy if they are on celecoxib?
For an individual with a diagnosis of ET and an indication for aspirin (81-100 mg PO daily), the concurrent use of the COX-2 inhibitor celecoxib would not lead me to hold aspirin. Available studies do not suggest that Celecoxib interferes with the antiplatelet effects of low-dose aspirin in a signif...
Do you screen children with sickle cell disease for silent cerebral infarcts?
We screen children with sickle cell disease for SCIs at our center. This is because data suggest that silent cerebral infarcts (SCIs) are much more common than overt stroke and the long-term negative impacts of SCIs are significant. There are also treatments (e.g., chronic transfusion and stem cell ...
Is there therapeutic relevance for FLT3-ITD mutation in relapsed APML?
FLT3-ITD mutations are seen in anywhere from 12-38% of APL cases, and there are conflicting data on the prognostic impact of the mutation on outcomes (Kuchenbauer et al., PMID 16029447, Beitinjaneh et al., PMID 20096459, Kiyoi et al., PMID 9305596, Kainz et al., PMID 12522450, Schnittger et al., PMI...
What is your preferred management for renal artery thrombosis causing renal infarct of unclear etiology?
This is a rare, under-recognized, and clinically challenging situation that has been debated for years, primarily because it falls within an evidence “gray-zone.” When evidence is lacking, opinions are abundant, and practice variations are substantial. In general, it is crucial to distinguish betwee...