Hematology
Clinical discussions on blood disorders, coagulation, transfusion medicine, and hematologic malignancies.
Recent Discussions
Would you continue or stop anticoagulation for a DVT/PE in a patient with active cancer who has completed 6 months of therapy?
This is an important question that we didn’t really have a clear answer for… until this year when an NEJM RCT was published! Mahé et al., PMID 40162636 In this RCT, patients with cancer-associated VTE who completed 6 months of full-dose apixaban were randomized to half-dose apixaban vs. full-dos...
How do you manage erythrocytosis secondary to sotatercept for patients with PAH?
I have not done that yet, but I have let Hgb drift up to 18-19 and monitor the patient closely. I lower the dose to 0.5 or even 0.3, if Hgb is high at baseline, then start and stay at 0.3 before I increase. I will consider phlebotomy if the above options are not available.
Do you routinely evaluate patients with collagen disorders or Ehlers-Danlos for platelet defects?
Yes, I routinely carry out a full hemostasis evaluation, including platelet aggregation and release studies, in patients referred to me with easy bruising and hypermobility with an increased Beighton score suggesting EDS and in those already diagnosed genetically with EDS. EDS patients typically hav...
What are the best labs to trend improvement in HLH?
Unfortunately, there is not one specific laboratory test to definitively trend responses to HLH directed therapy. In general, our approach is to obtain baseline inflammatory labs including CBC with differential, ferritin, soluble IL2 receptor (sIL2r), triglycerides, coagulation studies (PT/PTT) incl...
Would you offer live vaccines (e.g., MMRV/measles) to patients on bispecific antibodies for multiple myeloma?
I agree with the answer here by Dr. @Dr. First Last. There are a lot of nuances, though. In regard to giving the vaccine safely and effectively, the best strategy is not to wait until patients have multiple relapses and are on bispecific therapy to vaccinate. Given the recent outbreaks of measles, i...
How do you determine the optimal duration for 1L doublet treatment in newly diagnosed High-Risk CLL?
Among patients with high-risk CLL and indications for treatment per iwCLL criteria (Hallek et al., PMID 29540348), treatment regimens can be broadly categorized into fixed-duration, MRD-guided, and indefinite therapies. Fixed-duration doublet regimens include acalabrutinib with venetoclax per the AM...
How do you approach initial anticoagulant selection in hemodynamically stable hospitalized patients with newly diagnosed pulmonary embolism?
Low-molecular-weight heparin demonstrates the greatest benefit in patients with cancer-associated pulmonary embolism, intermediate-risk PE, and those requiring outpatient management. While LMWH shows superior efficacy and safety compared to unfractionated heparin across most patient populations, cer...
What is your preferred 1L treatment for newly diagnosed Del(17p)/TP53 mutation, high-risk CLL?
For patients with TN-CLL with TP53 aberration, the treatment options are usually based on patient factors. If a patient is a candidate for combination therapy, I prefer to treat them with uMRD-guided BTKi+BCL2i ± CD20 mAb. I only add a CD20 mAb to patients with no history of frequent infections and ...
For transplant-ineligible aplastic anemia planned for immunosuppression, how do you approach duration and tapering of cyclosporine and eltrombopag?
One of the most common mistakes in the management of AA is premature tapering of cyclosporine or tacrolimus. If there is a complete remission, and by that I mean normalization of counts, not complete remission as defined in some papers (e.g., ANC 1000, Plts 100,000, Hb 10 as in de Latour et al., PMI...
What is your preferred assay for assessing dabigatran levels?
The only specific assay that would reflect drug levels is the ecarin clotting time with dabigatran as a calibrator. We used to have this assay in our lab, but due to a lack of use, it was discontinued. The standard thrombin time is too sensitive; however, dilute thrombin time has been used. The mass...