Hematology
Clinical discussions on blood disorders, coagulation, transfusion medicine, and hematologic malignancies.
Recent Discussions
What approaches can we take to initiate therapy and improve survival rates in patients with HLH?
At our institution, we have comprised a multidisciplinary team to help treat these patients. The team or "HLH task force" as we like to call ourselves is comprised of a clinical immunologist, rheumatologist, dermatologist, critical care physician, hepatologist, BMT attending/hematologist, infectious...
What is your approach to iron deficiency anemia after a negative EGD and colonoscopy?
Cross-sectional imaging is the next step to evaluate the small intestine, which cannot be easily assessed by standard endoscopy. This will show whether there are masses or inflammation, and, if you do a triple-phase CT, whether there are large vascular lesions that could be the source of bleeding. A...
How do you manage patients with atrial fibrillation having a thromboembolic infarct despite being on adequate anticoagulation?
This scenario is always challenging. In terms of anticoagulation, the efficacy of DOACs in preventing embolic events in AF patients is around 70%, which is impressive compared to warfarin but not foolproof. In cases of a second embolic event while on anticoagulation, two reasonable approaches are of...
Do you check LDH levels for patients with CLL who are asymptomatic and on surveillance?
I personally include LDH as part of my routine chemistry panel monitoring of CLL in surveillance for several reasons. Often, patients with CLL can show up with new anemia; in such cases, the differential diagnosis is autoimmune hemolytic anemia versus disease progression. An elevated, new LDH level ...
What clinical or logistical factors influence your choice of anti-CD38 antibody in first-line treatment of multiple myeloma?
I generally use daratumumab, because subcutaneous is more convenient for patients, and we go to once-a-month dosing much quicker with daratumumab compared to isatuximab. Once isatuximab subcutaneous is available, this advantage of daratumumab may be lost, but given comfort and familiarity with darat...
Do you see a role for omidubicel upfront in severe aplastic anemia for patients without a matched donor?
We typically use cord blood products if there is no available family member donor or reasonably matched unrelated donor. The use of haploidentical family donors is very effective, less expensive, and allows supplementation with CD34+ stem cell boosts if counts are suboptimal DeZern et al., PMID 3234...
Do you consider bleeding risk in elderly, frail patients with atrial fibrillation to be similar for all NOACs?
I believe that apixaban carries a lower risk of bleeding, with particular reference to GI bleed, when compared to rivaroxaban and dabigatran. This is true in the population of AF patients at large and most probably in frail patients as well.
How do you manage catheter-associated, upper extremity superficial venous thrombosis?
I manage catheter-associated upper extremity superficial venous thrombosis (SVT) conservatively with arm elevation, warm compresses, NSAIDs, and topical creams containing NSAIDs. Upper extremity SVT is primarily caused by indwelling intravenous catheters, so I do strongly recommend catheter removal ...
How do you approach the risk/benefit discussion for IV iron in a patient with concomitant severe iron deficiency and elevated hematocrit due to supra-physiologic testosterone supplementation?
I only administer iron if symptomatic (pagophagia, RLS, etc). I have not seen iron deficiency with testosterone prior to phlebotomy. When it is required, I literally walk both sides of the aisle. If a non-phlebotomized patient presented with ID, I would work it up like any other. If I have to treat,...
What is your preferred first line treatment regimen for patients with untreated transplant-ineligible MM?
For transplant-ineligible patients, there are many excellent choices, including RVD lite and Dara Rd. My practice has shifted to Dara Rd for several reasons: The HR for Dara Rd v. Rd which is 0.56 appears to be better than the HR for RVd v. Rd in SWOG 0777, where it was 0.712 (though it should be no...