Hematology
Clinical discussions on blood disorders, coagulation, transfusion medicine, and hematologic malignancies.
Recent Discussions
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...
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...
Do you routinely check serum phosphorus levels after IV iron therapy?
Only before and after FCM. I hold subsequent doses if phosphorus low. There is no need to monitor with the other formulations. For people needing multiple doses of IV iron (IBD, bariatric surgery, heavy uterine bleeding, angiodysplasia), I avoid FCM.
Do you recommend vitamin C supplementation with PO iron in patients with iron deficiency?
Vitamin C supplementation is unnecessary. Taking the iron with a glass of orange juice away from food and especially coffee optimizes absorption. That being said vitamin C does no harm. See vonSiebenthal et al eClinical Works 2023 (Lancet publication), Benson et al, Lancet Haem 2025 or Auerbach et a...
When would you use AVD + brentuximab instead of ABVD for newly diagnosed stage 3 or 4 Hodgkin lymphoma?
By reducing the risk of primary treatment failure from 23% to 18%, the ECHELON-1 study demonstrated that compared to ABVD, AVD + brentuximab vedotin reduces the risk of primary treatment failure by about 25% for patients with advanced-stage classic Hodgkin lymphoma. If given with prophylactic G-CSF,...
Should all patients diagnosed with B12 deficiency get a baseline EGD?
It is important to determine the cause of B12 deficiency. The majority of cases are due to pernicious anemia (atrophic gastritis and lack of intrinsic factor), I presume this question relates to that group. If there is another cause such as intestinal malabsorption or bacterial overgrowth, this does...
How do you decide whether to use pharmacologic VTE prophylaxis in hospitalized patients with decompensated cirrhosis?
For all patients, I begin by using a standard risk prediction tool to determine if the patient is appropriate for pharmacologic VTE prophylaxis. At our institution, the Padua risk prediction tool is embedded in our electronic health record/admission set. Clinical guidelines- including those from the...