Hematology
Clinical discussions on blood disorders, coagulation, transfusion medicine, and hematologic malignancies.
Recent Discussions
What factors do you consider before discharging an MGUS patient from hematology clinic to safely follow with outpatient PCP?
In general, I follow the risk stratification referenced in the Mayo Clinic's recent review, and I tend to think about a clinic discharge from hematology if they have low-risk MGUS, i.e., serum M protein <1.5 gm/dL, IgG subtype, normal FLC ratio (0.26-1.65).I then use the Lee Index to estimate the pa...
Do you consider co-prescribing hormone therapy and anticoagulation in a patient with prior DVT and uncontrollable VSM uncontrolled by non-hormonal therapies?
While I agree that you need to be thoughtful about adding additional VTE risk to patients with a history of VTE, I am much less concerned when patients are already on full-dose anticoagulation. Especially when the medication is transdermal estrogen, which has the lowest effect on thrombotic risk. I ...
How would you manage a patient with HbSS and severe pulmonary hypertension on home oxygen?
This patient should be referred to a specialist in pulmonary hypertension in sickle cell disease for right heart catheterization and aggressive management of the pulmonary hypertension. As described, the patient is not a good candidate for lung transplant or gene therapy.
How would you manage symptomatic, bilateral subsegmental PE developed after long air travel?
I generally consider air travel to be a relatively weak provoking factor. Although the 2020 ASH guidelines do not address this, the ASH Guidelines from 2018 on management of VTE cite a 2.8-fold increased risk for VTE associated with air travel, which is roughly similar to the increased risk associat...
How do you approach perioperative hemostatic management for a patient with severe factor 11 deficiency <1%, without inhibitor, who has a significant postoperative bleeding history despite FFP prophylaxis who is undergoing major ENT/skull-base surgery?
This is a complex group of patients. There are systematic reviews that one could look up (Al-Housni et al., PMID 42189746). They involve various combinations of FFP transfusion, rFVIIa, and antifibrinolytics. Our practice has been to risk stratify the surgery based on the patient's personal bleeding...
Is there any indication for IVIG in immunocompromised patients with only decreased IgM and/or IgA levels?
Nope. IVIG preparations contain IgG not IgA or IgM. Low serum IgA may or may not be associated with low IgA levels in mucosal surfaces leading to a risk of local infections. Low levels of one or both may be asymptomatic but in the right setting might suggest a need for evaluation of plasma cell dysc...
What is your approach to iron deficiency anemia after a negative EGD and colonoscopy?
If there is no sign of atrophic gastritis and repeated fecal tests for blood are negative, I’d look first for celiac disease. If all the celiac screening tests rule it out, then I might team up with a hematologist to look for rare birds like transferrin deficiency. I’d probably ease back on PPIs if ...
How do you counsel patients who experience diarrhea from mycophenolate mofetil (Cellcept)?
I have them stop the drug, and when their bowels are back to normal (usually just a couple of days), I resume with 1 tablet bid of mycophenolate mofetil (MMF, CellCept), then a few days later go up to 1 tab tid, a few days later 2 tabs bid... etc. I instruct them to go down to the most recent dose ...
For iron deficiency anemia due to heavy menstrual bleeding, what is your preferred method of controlling heavy menses?
I definitely loop in my GYN friends for this one! According to ACOG: "Heavy menstrual bleeding is defined as excessive menstrual blood loss that interferes with a woman's physical, social, emotional, or material quality of life." The consequences of HMB are substantial and multifaceted, and, as we f...
For patients with multiple myeloma receiving bispecific antibodies who have had a slightly extended treatment interval beyond what the FDA label specifies, is repeat step-up dosing clinically necessary, or are there situations where it can be safely omitted?
The data underpinning this label is what was done based on protocols that were written before much of the pharmacokinetics was known, and certainly before a pharmaceutical company was willing to adjust these safety practices; they would be severely financially penalized if safety events disrupt drug...