Hematology
Clinical discussions on blood disorders, coagulation, transfusion medicine, and hematologic malignancies.
Recent Discussions
In what clinical scenario would you consider liver transplant evaluation for a patient with sickle cell hepatopathy?
We have evaluated and transplanted patients with sickle cell hepatopathy with severe liver dysfunction but well-controlled sickle cell. These patients will typically have jaundice, coagulopathy, and biliary strictures. They should not have significant extrahepatic complications of the hematologic di...
How do you decide whether to hold acalabrutinib or zanubrutinib in patients with indolent B-cell lymphoma/leukemias in a perioperative/periprocedural setting?
This is always a point of discomfort among providers, but it can actually be made quite easy. BTK inhibitors have known antiplatelet effects similar to low-dose aspirin. Consequently, if the surgeon holds aspirin for the planned procedure, I generally recommend that we hold the BTK inhibitor for 3 d...
Do you check IGHV mutation status in patients with newly diagnosed CLL?
Yes. In the targeted therapy era, there are three factors that continue to have prognostic and therapeutic significance and should be checked: IgHV mutation status p53 aberrancy - requires both FISH for del17p AND mutation analysis for p53 Complex karyotype - can be done on peripheral blood or marr...
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 GDMT do you recommend for patients with AL amyloidosis and systolic heart failure?
You are correct that cardiac amyloidosis patients do not tolerate most of the GDMT. SGLT2i may be helpful for both diuresis as well as HFpEF, and we do try to start this. Generally, they do not tolerate ARB/ACEI or even beta blockers. We find that torsemide seems to have better GI absorption and thu...
How do you approach patients who are inappropriately worried/fixated on a test result that is flagged as abnormal but not clinically significant?
I emphasize that the reference range intentionally excludes normal individuals who are a little different from the average person, and that the reference range is just a numerical exercise and general guidance, not something that was ordained by higher powers. I don't use the analogy for patients, b...
For atrial fibrillation patients with high risk of CVA who cannot tolerate full dose AC due to bleeding, do you consider low dose/extended dosing anticoagulation even if they do not meet age/GFR criteria for a dose reduction, if Watchman is not readily available as an option?
Most drugs, including anticoagulants, have a dose-response. Therefore, one could argue that even though DOACs were not studied at low doses, except in defined sub-groups such as the very elderly, using such a dose in other situations may have some benefit. The problem is that without data, we simply...
In your practice, what premedications do you use for subcutaneous daratumumab?
We administer the following pre-infusion medications 1 hour to 3 hours before the first 4 SQ infusions, and then we drop all premedications (except for dexamethasone) thereafter: Dexamethasone 20-40 mg Acetaminophen 650 mg Diphenhydramine 25 mg Montelukast 10 mg [this is not in the package insert b...
For patients with newly diagnosed unmutated CLL how will you decide between BTKi alone vs Ven/BTKi vs Ven/Obin vs Ven/Obin/Acalabrutinib?
My usual practice has been Ven Obin for most patients, even unmutated, but if they have bulky nodes and are young/fit, I am now adding acala to that and giving the 3-drug regimen. Continuous BTKi in my practice is mostly reserved for the older or less fit patients, or those who really, really don’t ...
What is your approach to VTE prophylaxis in hospitalized patients who are already on DAPT?
DAPT by itself is not considered DVT prophylaxis in patients at high risk of DVT. However, LMWH at prophylactic doses can increase the need for transfusions in patients on DAPT, without decreasing VTE rates. In general, I consider patients individually: Do they still need DAPT? With discontinuity o...