Hematology
Clinical discussions on blood disorders, coagulation, transfusion medicine, and hematologic malignancies.
Recent Discussions
How would you work up a patient with cutaneous mastocytosis?
In adults, consider mastocytosis as being systemic until you prove it is not. A single normal or low-elevated tryptase does not eliminate the possibility of systemic mastocytosis. All patients should go to Heme/Onc for consideration of bone marrow biopsy and ideally high-sensitivity PCR to look for ...
What is the utility of a hypercoagulability workup in recurrent cryptogenic stroke, and what specific tests would you recommend?
Ambulatory monitoring for AFib is probably more helpful than such a thorough clotting workup.
What induction regimen would you consider for KMT2A-rearranged AML in a young patient with multiple medical co-morbidities who is ineligible for clinical trials?
Given the mention of medical comorbidities and ineligibility for trials, I am going to assume that the patient cannot be treated with an intensive induction regimen. With this in mind, a lower-intensity approach such as azacitidine + venetoclax would be my recommendation. Survival outcomes in adult ...
Does anyone utilize P2Y12 assays to determine if clopidogrel may be ineffective when used for DAPT?
Yes, I use P2Y12 assays in two distinct settings. Medical management: If a patient on clopidogrel mono/dual therapy has disease progression with ICAD or experiences a recurrent ischemic event, I obtain a P2Y12 assay to assess responsiveness. This helps guide the decision to switch to ticagrelor and ...
What is the preferred approach for an AYA patient with VHR B-ALL with iAMP21 mutation with an isolated early CNS relapse?
For relapsed high-risk disease such as iAMP21, the recommended approach is to achieve remission followed by consolidation with allogeneic stem cell transplantation. However, in cases of isolated CNS relapse, I favor CAR T-cell therapy first to achieve and deepen CNS remission, as it has demonstrated...
What is your standard for monitoring triglyceride level during therapy for ALL, particularly in regards to receiving pegaspargase?
Routine monitoring of triglyceride levels is not considered standard practice during pegaspargase therapy. Although hypertriglyceridemia is a common side effect of asparaginase treatment, it typically has no significant clinical impact on management decisions or future use of asparaginase. The condi...
What parameters would you use to monitor and interpret iron levels in a hemochromatosis patient where ferritin is unreliable due to underlying chronic inflammation?
The biggest question in these situations is whether the patient truly has iron overload vs. just high ferritin. If iron sat is not elevated, true iron overload is very unlikely. If both ferritin and iron sat are elevated, but they don't have a homozygous C282Y genotype, I make sure that the patient ...
Would you recommend indefinite or extended anticoagulation in any scenario of a provoked clot?
The answer, like most decisions with the duration of anticoagulation after a VTE, is it depends. The provoking factor is key to determining whether anticoagulation continuing beyond the treatment of the acute event is needed. If the provoking factor was a joint replacement surgery, even in the prese...
How do you think about using Ropeginterferon Alfa 2B for polycythemia vera in patients with active autoimmune disease?
Great question. In general, I avoid interferons in patients who have an autoimmune disease. In the PROUD-PV/CONTI-PV study, a medical history of autoimmune disease was an exclusion criterion. There have been reported cases of interferon-induced autoimmune disease, most commonly autoimmune thyroiditi...
How do you manage reactive thrombocytosis and potentially symptomatic fatigue from JAK2+ P Vera with iron deficiency?
This is a challenging scenario since if you start supplementing iron, you can increase erythropoiesis, raise the hematocrit, require more therapeutic phlebotomies, and end up chasing your own tail. For these reasons, I generally recommend against iron supplementation in PV. Regarding the fatigue and...