Hematology
Clinical discussions on blood disorders, coagulation, transfusion medicine, and hematologic malignancies.
Recent Discussions
How do different inflammatory markers like CRP and ferritin contribute differently, if at all, to the monitoring of CART neurotoxicity?
These markers are routinely monitored as they are seen in association with CRS (cytokine release syndrome). Not all patients with CRS will also develop neurotoxicity (ICANS), but most patients with ICANS have antecedent CRS, so in an encephalopathic patient post-CART who does not have significant el...
When would you use proximal complement inhibitors like pegcetacoplan over terminal complement inhibitors for initial treatment of paroxysmal nocturnal hemoglobinuria?
I use either iptacopan or pegcetacoplan as primary therapy for PNH these days. Since its release, I have used mainly iptacopan. Its advantages are 1) it is oral, 2) the side effect profile is very tolerable, 3) it only inhibits the alternative pathway, thus is likely to be associated with less risk ...
When MGUS is suspected in a patient with one risk factor and no evidence of end-organ damage, what additional workup should be done, if any?
My approach applies only for the scenario of thinking about monoclonal gammopathy -> myeloma spectrum. Monoclonal gammopathy -> amyloidosis or MGRS/MGNS, etc. I think of quite differently.Our VA pathways and other organizations have advocated for bone marrow biopsy in this situation. For example, in...
How would you manage recurrent migratory lower extremity thrombophlebitis that occurs despite being on therapeutic apixaban?
The differential diagnosis of Trousseau syndrome (migratory superficial thrombophlebitis) is relatively broad and includes both inflammatory states and undetected proximal DVTs. So I think the short answer about venogram is "maybe," based on how clear is the view by ultrasound. This isn't a typical ...
Now that ropeginterferon is approved for PV, how do you select patients for this therapy?
First, I have no conflicts of interest with respect to ropeginterferon (rPegIFN). rPegIFN is a long-acting version (once every two weeks administration) of pegylated interferon (PegIFN) as opposed to once per week, which has been used for decades for the treatment of CML and MPN patients, without ra...
In a patient with history of recurrent VTE despite anticoagulation, would you consider lenalidomide as part of your initial myeloma regimen?
I would still consider lenalidomide as part of the initial myeloma regimen provided that they were on therapeutic dose anticoagulation (my preference is apixaban 5 mg BID or rivaroxaban 20 mg daily). Ideally, this would be started at least 3 months after therapeutic dose anticoagulation for the most...
How do you decide when, if ever, to defer pharmacologic venous thromboembolism prophylaxis for hospitalized patients?
For the majority of patients who are not actively bleeding, I use pharmacological prophylaxis. I prefer heparin products, unless they have a history of HIT or religious preferences on porcine products. Even for patients planned for surgery, heparin can always be held or reversed. I prefer LMWH over ...
What could explain discordant iron studies?
This is an incredibly common question, largely generated by the zeal to use the serum ferritin and failure to appreciate the need for an overnight fast when ordering the TSAT (the ferritin does not require fasting). The most common culprit in this situation is iron containing vitamins. Prenatal vita...
At this time, how are you using MRD testing for clinical management of patients with multiple myeloma?
Off a clinical protocol, I only routinely use MRD (clonoSEQ) in a very specific setting. That setting is low risk patients who have received autologous transplant as part of first line therapy and did well. Specifically, if the patient's response to first line therapy is VGPR or better at day+60, th...
In which cases would you consider early transition to DOAC (within 72 hours) for hospitalized patients with intermediate or high risk PE?
Two DOACs are FDA-approved for early use (within 72 hrs), rivaroxaban and apixaban. The PEITHO-2 dabigatran cohort study included no comparison group (its authors called it a "trial"?) and required "72 hrs" parenteral anticoagulant before dabigatran but the small print in its Lancet Haematology show...