Hematology
Clinical discussions on blood disorders, coagulation, transfusion medicine, and hematologic malignancies.
Recent Discussions
Would you extend the duration of anticoagulation in patients with a provoked DVT, but evidence of residual clot at 3 months?
This is a really interesting discussion. I do tend to get Dopplers at the end of the anticoagulation treatment period, but only to assess the new baseline and to help decision-making in the future if they develop new symptoms and have another Doppler. I find this to be very helpful to understand if ...
In patients with post-PV myelofibrosis who are ineligible for allogeneic stem cell transplant, how do you approach symptomatic splenomegaly refractory to splenic radiation and ruxolitinib?
This is always a tough situation. First, I would make sure the patient is truly not a candidate for transplant. With reduced intensity conditioning and the addition of ruxolitinib before and after transplant, transplant is better tolerated than it once was. Otherwise, would consider switching to ano...
How would you approach management and monitoring of AL amyloidosis with isolated renal involvement?
This is tough for sure, and my first question would be to ask how the renal biopsy was determined to be AL amyloidosis. Sometimes typing isn't required if the pattern is overwhelmingly lambda-restricted or kappa-restricted by immunofluorescence... but in this case, mass spectrometry typing may be wo...
How would you treat an elderly newly diagnosed tDLBCL that has previously seen R-CHOP and Bendamustine-Obinutuzumab prior to the transformative event?
I would give tafasatimab and Revlimid per the L-MIND study. I have been so impressed by this well tolerated immunotherapy regimen and the durability of responses. Literally, it looks competitive with car T cell therapy. Car, T cells would be an option, if the patient is very fit for their age and th...
When starting a patient on a tyrosine kinase inhibitor for chronic phase CML, which drug do you choose upfront?
Randomized clinical trials with nilotinib and dasatinib versus imatinib have shown improved rates of molecular response for the second-generation TKIs:https://www.ncbi.nlm.nih.gov/pubmed/24311723https://www.ncbi.nlm.nih.gov/pubmed/20525993https://www.ncbi.nlm.nih.gov/pubmed/20525995Improved response...
What factors do you consider when choosing between a 1st and 2nd generation TKI in a newly diagnosed CML patient?
I consider disease risk, patient comorbidities, and current medications taken. First, if a patient has low risk disease, any of the approved TKIs in first line are acceptable. If the patient has higher risk disease, I generally do not start imatinib. In terms of picking amongst the TKIs, I prefer to...
Would testing for ATTR cardiac amyloidosis be considered in an older patient with bilateral carpal tunnel surgeries and multiple spinal stenosis surgeries, but no obvious cardiac symptoms?
I would not look for ATTR-CM in the absence of cardiac findings such as abnormal echo (increased LV thickness) or conduction abnormalities that are suggestive. Only 10% of patients with bilateral CTS have ATTR-CM. I would do an echo if not done and review ECG. As much as we are concerned about under...
How do you anticipate rusfertide will be used in the management of polycythemia vera?
Rusfertide, an injectable hepcidin mimetic (1), is another new arrow in the quiver of 21st-century therapies for controlling erythropoiesis without phlebotomy in polycythemia vera (PV), though likely to be replaced in the near future by gene silencing technology, which does not require as frequent d...
Are there different strategies you would utilize to monitor and manage potential resistance in patients with CML receiving asciminib?
Overall, I use similar monitoring strategies for all CML therapies, including what responses or loss of response prompt me to consider assessment for mutations that confer therapy resistance. Sometimes it is difficult to differentiate non-adherence vs emerging resistance, and thus it is important to...
What is your approach to persistently low INR despite escalating doses of warfarin in a patient with bioprosthetic mitral valve replacement who is unable to be on DOACs?
The assumption here is that the mitral valve is mechanical, or there are presumably other reasons that a DOAC cannot be used. If this is, in fact, a mechanical mitral valve, it would make sense to start with low molecular weight heparin injections as soon as feasible while awaiting a therapeutic INR...