Hematology
Clinical discussions on blood disorders, coagulation, transfusion medicine, and hematologic malignancies.
Recent Discussions
How do you manage anticoagulation/antiplatelet therapies with strong indications for uninterrupted therapy in the setting of urgent procedures?
If anticoagulation is absolutely contraindicated because of the bleeding risk of the procedure, then "bridging" will usually make the most sense, most of the time, with low molecular weight heparin such as enoxaparin. If dual antiplatelet agents are contraindicated, particularly in the first month a...
Is there benefit to aggressively treating hemochromatosis in a patient who has already progressed to cirrhosis at the time of diagnosis?
The short answer is yes, there is a benefit to treating iron overload in a patient with hereditary hemochromatosis (HH) with cirrhosis. HH involves at least five mutations, most commonly in the HFE gene (common variants include C282Y and H63D), leading to hyperabsorption of iron and progressive accu...
What would be your preferred anticoagulant for recurrent DVT/PE in a patient on hemodialysis with calciphylaxis and prior DOAC failure?
A truly complex case: recurrent DVT/PE in the setting of ongoing risk factors for both VTE (active calciphylaxis, prior DOAC failure, and obesity) and bleeding (ESRD on hemodialysis), each of which constrains a different anticoagulant option. Given the complexity and rarity of this case, recommendat...
For which patients with relapsed/refractory follicular lymphoma do you prefer bispecific antibody-based therapy at 2L vs reserving it for later?
Bispecific antibody-based therapy for 2L FL is a very effective treatment option with high rates of overall response, complete response, and what thus far appears to be durable responses. In the EPCORE FL-1 trial, where patients were randomized to epcoritamab + R2 vs R2, it did add more toxicity to ...
What is your preferred first line treatment regimen for patients with untreated transplant-ineligible MM?
For transplant-ineligible patients, there are many excellent choices, including RVD lite and Dara Rd. My practice has shifted to Dara Rd for several reasons: The HR for Dara Rd v. Rd which is 0.56 appears to be better than the HR for RVd v. Rd in SWOG 0777, where it was 0.712 (though it should be no...
In patients with iron deficiency due to history of gastric bypass or IBD, would you consider oral iron therapy if the iron deficiency anemia is mild?
Oral iron can often be effective in iron deficiency, as long as absorption is intact. If you are concerned about absorption, performing an oral iron challenge can be useful in allowing you to avoid long trials of oral iron that will be ineffective. Simply check an iron panel at baseline, then admini...
What is your treatment of choice for triple class refractory multiple myeloma?
To define triple-class refractory means the patient is refractory to FDA-approved IMiDs (up to Pomalidomide), proteasome inhibitors (bortezomib and carfilzomib), and CD38 naked antibodies (e.g. daratumumab or isatuximab). Refractory is defined as progression or within 60 days of the last dose. I ag...
How would you approach anticoagulation for a patient with acute bilateral pulmonary emboli related to malignancy, but with a concomitant cavitary lung mass experiencing episodic, small-volume hemoptysis?
This is an interesting question to which we need to apply the art of medicine, weighing the risks and benefits of treatment. The major fatal events in this exact scenario are: Recurrent PE from undertreatment. Sudden massive hemoptysis after aggressive anticoagulation. The physician's management s...
When testing for patients with symptoms of MPN, do you prefer to do JAK2 cascade testing or a leukemia NGS testing panel?
Genetic testing with regard to the MPN can be usefully employed both diagnostically and prognostically. With respect to diagnosis, if an MPN is suspected based on symptoms such as aquagenic pruritis, ocular migraine, erythromelalgia, or the occurrence of an unexplained thrombosis, the first laborato...
In low-risk MDS patients with symptomatic anemia and a low EPO level, how does the presence of a high-frequency SF3B1 mutation influence your first-line choice between an ESA and luspatercept?
I would consider the SF3B1 mutation to be the relevant biomarker for the selection of frontline therapy (namely luspatercept) in this case. The correlation between SF3B1 mutations and the presence of ring sideroblasts in MDS is strong but not perfect. This could be for a variety of reasons, the most...