Hematology
Clinical discussions on blood disorders, coagulation, transfusion medicine, and hematologic malignancies.
Recent Discussions
How do you incorporate CAR-T cell therapy for DLBCL in transplant-eligible patients?
The role of sequential therapy including CARs vs high dose chemotherapy + ASCT post primary induction failure/relapse in large cell lymphoma is a matter of active research. Given the present FDA indication of CARs is in relapsed/refractory large cell lymphoma after failure of at least 2 lines of pri...
Does stopping anagrelide affect fibrosis in patients with ET who develop post-ET myelofibrosis?
Anagrelide is a phosphodiesterase (PDE) III inhibitor, developed initially as a platelet antiaggregant, but was found to have platelet lowering activity at concentrations lower than its platelet antiaggregant activity. Thus, it was consequently marketed to reduce thrombocytosis in MPN patients. It i...
Would you recommend an allogenic stem cell transplant in an older patient > 50 with Ph negative acute lymphoblastic leukemia who is MRD negative after induction?
In general, I would not routinely recommend allogeneic hematopoietic cell transplantation (HCT) for Ph- acute lymphoblastic leukemia (ALL) that is in MRD-negative remission this early in their treatment. This sort of response demonstrates significant chemosensitivity. Therefore, I would favor contin...
Are you more permissive of perioperative interruption of anticoagulation for VTE depending on the location and relative chronicity of the thrombus?
Yes - in general, I try to balance the relative urgency/importance of the procedure or surgery v. the thrombotic risk to the patient of a period of time off of anticoagulation. Location and chronicity both can feed into determining thrombotic risk. An upper extremity DVT, in general, has a lower rec...
How would you manage symptomatic superficial vein thrombosis during pregnancy?
The best evidence for the treatment of SVT comes from the CALISTO trial, which endorsed a prophylactic dose of fondaparinux as the treatment of choice. However, the CALISTO trial excluded pregnant women. Because data on the use of fondaparinux in pregnancy remain limited, with some traces of fondapa...
Are there data to support full-dose anticoagulation added to an antiplatelet in recurrent peripheral arterial thrombosis requiring revascularization and stenting?
This question comes up frequently at our institution. I previously consulted with our vascular surgery team who referred me to this trial of Edoxaban with SAPT, trying to avert what may be limb loss if the bypass graft/stent fails. We've often promoted rivaroxaban 2.5 mg po BID per VOYAGER PAD if we...
When should you use caplacizumab in the treatment of acute TTP patients?
Whenever I encounter a patient with features of thrombotic microangiopathy and a normal coagulation panel (that rules out DIC), I consider the possibility they may have immune TTP.If my suspicion of immune TTP is high (e.g. history of autoimmune disease, possible relapse of immune TTP) and there is ...
What is your approach to the management of unprovoked distal DVTs?
The management of distal deep vein thrombosis (DVT)—[involving the peroneal, posterior tibial, anterior tibial, or the muscular calf veins (gastrocnemius and soleus); proximal DVT, by contrast, refers to thrombosis in the popliteal, femoral, or iliac veins]—is evolving in step with broader changes i...
How would you approach escalation of therapy in an adult patient with refractory Still’s disease and associated MAS/HLH (ferritin >100,000, transaminitis, DIC) despite high-dose steroids, high-dose anakinra, tocilizumab, and ruxolitinib?
Emapalumab is an appropriate escalation in the described circumstance. I have no experience, and there is little published data as of yet with MAS825, but I would position this as an option to pursue before using etoposide. While there may be an indication of confounding, etoposide use nonetheless h...
What is your approach to IV fluid resuscitation during a sickle cell vaso-occlusive crisis?
My approach to IV fluid resuscitation in vaso-occlusive crisis is cautious and individualized. Adequate hydration is important to prevent further sickling, but I avoid aggressive fluid loading because of the risks of pulmonary edema and acute chest syndrome. I typically use isotonic balanced crystal...