Hematology
Clinical discussions on blood disorders, coagulation, transfusion medicine, and hematologic malignancies.
Recent Discussions
What is a reasonable hemoglobin goal for patients with chronic anemia presenting with acute MI?
The diversity of acute myocardial infarction (AMI) does not allow a monolithic answer to this question. The recent MINT study—an important contribution presented at AHA 2023 and published in NEJM—highlights this complexity. Although MINT, which randomized anemic patients with AMI to liberal versus r...
Do you diagnose MCAS if a patient is concurrently on drugs known to cause non-specific mast cell degranulation?
Yes, MCAS may be diagnosed if a patient is on drugs known to cause non-specific mast cell activation.The reason for this answer requires a better understanding of MCAS criteria and etiology. In 2022, an expert consortium proposed revisions to the classification of mast cell activation disorders. (Va...
How do you manage patients desiring home hospice but with severe thrombocytopenia and/or anemia due to advanced malignancy?
As a pediatric hematologist/oncologist and pediatric palliative care physician, I can only speak to our approach with children, which may be quite different than the adult world. In our community, we are not able to provide blood or platelet transfusions in the home. For children who are profoundly ...
In which patients with atypical HUS would you consider eculizumab discontinuation?
My approach to eculizumab cessation in aHUS is to at least consider cessation in all patients not only given the high cost of the drug, but also given the risk of meningococcemia, which is incompletely protected against by vaccines.In treating aHUS, I initiate eculizumab (and preventive therapy for ...
Do you recommend GLP-1 agonists in patients with MPN?
I don't think that there is a compelling reason to start a GLP-1 agonist without another indication. With that said, there was a provocative recent abstract at SOHO suggesting a significant reduction in mortality, thrombosis, and disease progression in GLP-1-treated PV patients compared to those who...
How do you differentiate primary from secondary iron overload?
Medical history helps- transfusion history, chronic hemolytic anemias, ESRD on HD, and inflammatory conditions increase the risk of secondary iron. In my practice, I use MRI to help distinguish between primary and secondary iron overload. In primary iron overload, the iron will only be seen in the l...
Would it be reasonable to offer a patient with CLL a treatment break from acalabrutinib or any BTK inihibitor after a period of time, assuming good response?
It is certainly reasonable to take breaks and I have done this for certain patients in my practice. For example, in older or frail patients whose disease is already under great control, I think it is reasonable to have a “drug holiday”. With continuous long-term use, it is almost inevitable to run i...
When would you consider testicular RT prior to TBI for BMT?
In children with ALL treated with systemic chemotherapy alone (no transplant), the risk of testicular recurrence is ~15-20% (Br J Haematol 2003;123:396, Br J Haematol 1998;102:656). In adults with AML treated with standard chemotherapy, with or without transplant using a chemotherapy alone condition...
Will you recommend pirtobrutinib following a prior covalent BTKi in patients with cardiac comorbidities?
In the MCL patients treated on the BRUIN trial, treatment was well tolerated in general with a low rate of treatment discontinuation or dose reduction. As far as cardiac toxicities, no grade ≥3 treatment emergent AEs of hypertension were observed. Atrial fibrillation/flutter (AF) was reported in 6 (...
For patients with a history of pregnancy loss, do you evaluate for PAI-1 polymorphisms as part of a thrombophilia workup?
I do not.The relationship between PAI-1 polymorphisms and thrombosis is complicated, and general guidance suggests against assessing for PAI-1 overexpression as part of a thrombophilia workup. While there is some data to suggest an association between PAI-1 polymorphisms and pregnancy loss, ALIFE2 s...