Hematology
Clinical discussions on blood disorders, coagulation, transfusion medicine, and hematologic malignancies.
Recent Discussions
Should post-transplant cyclophosphamide be utilized for all matched unrelated donor peripheral blood stem cell transplants for hematologic malignancy?
In myeloablative transplantation, PTCY did not have an advantage over Tac/MTX as demonstrated in the BMT-CTN 1301 study which compared PTCY, Tac/MTX, and T cell depletion (Luznik et al., PMID 34855460). One caveat is that in this trial, PTCY based prophylaxis did not include Tac or Tac/MMF.BMT-CTN 1...
In a patient with cryptogenic stroke while on antecedent aspirin 81 mg, how do you decide between single antiplatelet therapy, dual antiplatelet therapy, or antiplatelet agent combined with anticoagulation such as rivaroxaban 2.5 mg BID?
This question assumes that a thorough workup has been completed, and the patient does not have paroxysmal a fib, a PFO, an intracranial stenosis, a hypercoagulable state, or vasculitis. This workup is the most important issue. If all is negative, and the stroke is relatively minor (NIHSS less than o...
What are alternative myeloma therapies for patients who are unable to afford lenalidomide or oral cyclophosphamide due to gaps in prescription drug coverage?
Unfortunately, this is a big problem, especially in community centers where the resources for grant applications are scarce. At bigger institutions, like ours, we have a dedicated person who searches for all possible grants. If unable to, then the pharma companies have been generous to give free dru...
For patients with essential thrombocythemia already on prophylactic dose DOACs, do you defer starting aspirin?
I usually defer aspirin in these situations. There is evidence from PV that aspirin plus anticoagulation increases bleeding risk (Zwicker et al., PMID 34162181). If an ET patient has a high-risk disease with prior arterial thrombosis, then I would favor adding aspirin.
Does evidence support extending the duration of intravenous iron dextran (INFeD) infusion in pregnant patients?
No, there has never been evidence with any of the four formulations supporting a longer rate of infusion (above the minimum recommended) as a harbinger of either benefit or safety. LMW ID (INFeD) should be given as 1000 mg in 250 ml of normal saline over one hour. My gut tells me 45 minutes is OK bu...
How do you counsel patients with acute intermittent porphyria when it comes to fasting for religious reasons?
This is a very difficult question and it depends on the individual patient, their disease severity, their particular triggers, and how they have done in the past with caloric restriction. The patient may want to speak with a clergy member for guidance in this situation as well. For inst...
How do you decide when to use andexanet (ANDEXXA) for intracranial hemorrhage associated with factor Xa inhibitors?
The ANNEXA-I trial presents a mixed perspective. The data demonstrated that Andexanet is superior to standard care in reducing hematoma expansion for intracerebral hemorrhage associated with factor Xa inhibitors. This conclusion is based on an imaging-based primary endpoint, supported by previous st...
How would you manage a patient who develops acute stroke during neoadjuvant chemotherapy with KEYNOTE-522 for Stage III triple negative breast cancer?
I will try to provide some data for discussion, but also welcome comments from other experts and opinions. I'm assuming this is a younger patient without known risk factors and that an assessment for things like A. Fib, PFO, and DVT have been performed.Chemotherapy has long been associated with thro...
Should you consider thromboprophylaxis, even for low-dose lenalidomide maintenance, post-autologous transplantation?
In the event there are no adverse contraindications for the use of thromboprophylaxis, yes, I recommend the use of a minimum of 81 mg of aspirin daily with a low dose of lenalidomide. In this meta-analysis (Chakraborty et al., PMID 31913498), the risk of venous thromboembolism was low with a low dos...
How would you approach a young person with JAK2 V617F positive essential thrombocytosis with otherwise low risk features?
The first question in this situation is what is the JAK2 V617F neutrophil quantitative allele burden (NAB)? It must be less than 50% for a diagnosis of essential thrombocytosis (ET). Second, are we dealing with a man or woman? Men with so-called "ET" are much more likely than women to develop myelof...