Hematology
Clinical discussions on blood disorders, coagulation, transfusion medicine, and hematologic malignancies.
Recent Discussions
Are there different strategies you would utilize to monitor and manage potential resistance in patients with CML receiving asciminib?
Overall, I use similar monitoring strategies for all CML therapies, including what responses or loss of response prompt me to consider assessment for mutations that confer therapy resistance. Sometimes it is difficult to differentiate non-adherence vs emerging resistance, and thus it is important to...
What is your approach to persistently low INR despite escalating doses of warfarin in a patient with bioprosthetic mitral valve replacement who is unable to be on DOACs?
The assumption here is that the mitral valve is mechanical, or there are presumably other reasons that a DOAC cannot be used. If this is, in fact, a mechanical mitral valve, it would make sense to start with low molecular weight heparin injections as soon as feasible while awaiting a therapeutic INR...
Is there specific data on using luspatercept for sickle beta+ thalassemia with transfusion-dependent anemia?
There is no data currently on the use of luspatercept in any condition other than beta thalassemia, including HbE-beta thalassemia. It has been studied in the beta thalassemia phenotype, both transfusion-dependent and non-transfusion-dependent (adult data published, pediatric trial underway), but no...
Does 4G/5G polymorphism in the plasminogen activator inhibitor (PAI-1) gene increase the risk of thrombosis?
Venous thromboembolism (VTE) is a classical example of a multifactorial disorder where genetic and environmental factors interact to result in VTE. Of the genetic disorders, in isolation, many are weak risk factors but when combined with other genetic or one or more environmental risk factors increa...
Is there any benefit of using aspirin to mitigate VTE risk in testosterone-induced polycythemia?
Erythrocytosis is a common adverse effect of testosterone therapy, and results from several studies suggest an association between elevated hematocrit (Hct) and risk of VTE (Braekkan et al., PMID 19833630; Ory et al., PMID 35050717). There is currently no data to support the routine use of aspirin o...
What level of 24h urine M protein do you consider to define active myeloma in a patient with renal insufficiency, proteinuria and monoclonal gammopathy?
When in doubt, a renal biopsy is preferred to define what is the exact disease process leading to renal dysfunction. If cast nephropathy is seen, this supports a diagnosis of myeloma. If amyloid or light chain deposition disease is seen, this also supports a diagnosis of amyloidosis or MGRS/myeloma,...
How do you manage copper deficiency?
Copper supplements are available. Would need to exclude zinc excess as a cause and to discontinue zinc supplements.
What factors do you consider when choosing between asciminib vs TKI in a newly diagnosed CML patient?
I think any patient is a good candidate for asciminib, with the exception of those with atypical transcripts (e.g., b2a3, b3a3). The decision would mostly depend on the goals of the patient and the availability and access. Asciminib is particularly well suited for patients who would be interested in...
How would you manage a pre-menopausal woman with extranodal marginal zone lymphoma confined to the bladder wall?
Marginal Zone Lymphoma (MZL) when localized is curable in most instances with modest doses of RT (24-30 Gy), perhaps even less when the primary site is the orbit. It typically responds to rituximab but relapses occur in most cases. Therefore, definitive RT is the treatment of choice in the great maj...
For primary MZL of the breast, do you do whole breast to 24 Gy or ISRT?
Without knowledge of the age of this patient and whether the concern of carcinogenicity from half the normal dose of traditional whole breast radiation (which we obviously do all the time for breast cancer) is enough to warrant omission of curative intent therapy in what is otherwise described as a ...