Hematology
Clinical discussions on blood disorders, coagulation, transfusion medicine, and hematologic malignancies.
Recent Discussions
How do you manage a patient with no history of miscarriage but who is unable to conceive, who has a positive lupus anticoagulant without diagnosis of antiphospholipid syndrome?
I would be very leery of linking infertility to a positive lupus anticoagulant result. Whether or not the patient has antiphospholipid syndrome the evidence linking antiphospholipid antibodies to infertility (as opposed to loss of an established pregnancy) is somewhere between weak and nonexistent. ...
What is your threshold for pursuing bone marrow biopsy in a lupus patient with cytopenias?
I rarely do bone marrow biopsies in patients with SLE as cytopenias are caused primarily by the disease itself and/or medications, primarily Azathioprine and Cyclophosphamide. SLE patients routinely have profound lymphopenia, neutropenia, and thrombocytopenia. I consider bone marrow biopsy in patien...
What is the appropriate dose of radiation for a primary osseous non-Hodgkin's lymphoma?
Acceptable doses range from 30 Gy to 45 Gy. Would consider 30 Gy if there is a metabolic complete response after 2 cycles of R-CHOP and the patient got at least 4 cycles total. 45 Gy is the dose used in the prospective TROG trial of bony DLBCL, so it has some data behind it. In the femur, the bigges...
Do you typically use NOACs or Lovenox in patients with stroke due to hypercoagulability from malignancy?
We can extrapolate from studies of venous thromboembolism associated with cancer. Apixaban (at VTE treatment dose) has been compared to dalteparin in an open-label RCT in the CARAVAGGIO trial and edoxaban was compared to dalteparin in an open-label RCT in the Hokusai VTE Cancer trial. Both painters ...
Do you typically recommend four factor prothrombin complex concentrate versus fresh frozen plasma for INR correction in patients with vitamin K antagonist associated spontaneous ICH?
Great question! Despite the lack of large randomized controlled trials, PCCs achieve faster reversal of the INR level than FFPs do, and thus I favor using PCCs with Vitamin K as a first line agent for Vitamin K antagonist related ICH.
What frontline therapy would you offer for a patient who is elderly or unfit for standard induction therapy with both IDH-2 and FLT-3 ITD mutations?
For a newly diagnosed patient, unfit for induction chemotherapy with both an IDH2 and FLT3 mutation, I would offer HMA with venetoclax for the initial treatment. While both the IDH2 inhibitor Enasidenib and the FLT3 inhibitor Gilteritinib are both well-tolerated drugs with good remission rates, if y...
How would you manage a patient with PV or ET who is experiencing breakthrough thrombosis?
The first question I would ask in this clinical situation is, "does the patient have PV or ET?"; a patient cannot have both. Unfortunately, I encounter this situation too often in my clinical practice. There appears to be a curious but dangerous belief in the medical community that ET is a more sero...
How would you approach treating patients with RA refractory to cDMARDs and a prior history of MALT lymphoma?
If the concern is the risk of recurrence of lymphoma in a patient with RA requiring DMARD therapy, particularly biologic DMARD therapy, rituximab has not been associated with recurrence or even new onset lymphoma. Rituximab is a highly efficacious biologic DMARD for seropositive RA. This is consiste...
In a patient with sickle cell disease on hydroxyurea who is planning to have a family, for how long should they be off the drug before trying to conceive?
There is some consensus that pregnant women should not take hydroxyurea and should stop taking this when found to be pregnant. (Smith-Whitley, PMID 25472967) As far as I know, there is no data on how long hydroxyurea should be discontinued in either men or women before attempting pregnancy. In fact,...
In sickle cell patients with continued pain crises despite hydroxyurea, how do we sequence the use of newer agents?
As the data supporting the approval of crizanlizumab in NEJM by Ataga et al demonstrated improvement in pain, that is our usual next agent based on the question of pain crises. The approval data around voxelotor related to an increase in hemoglobin of about 1gm/dl, so it may have a different role an...