Hematology
Clinical discussions on blood disorders, coagulation, transfusion medicine, and hematologic malignancies.
Recent Discussions
How would you treat an elderly male with history of mantle cell lymphoma who relapsed after chemoimmunotherapy and cBTKi w/ multiple co-morbidities including CKD and CHF w/ low EF?
There's obviously a lot of additional information that would help in making individual patient-level recommendations here. What was the first line of chemoimmunotherapy, and how was it tolerated? How long was his duration of response? How was the response to covalent BTKi in depth and duration? What...
Based on the ASC4MORE trial, would you add asciminib to imatinib if patients do not achieve deep molecular remission at 1-year?
This is hard to justify. If you are using asciminib, the patient likely has had resistance to several prior TKI's. In this setting, treatment discontinuation is not recommended outside of clinical trials. Achieving BCR::ABL1 <=1% is an adequate response likely to improve survival, and about 40% of p...
Are SCDs contraindicated in patients with acute DVTs?
SCDs can help prevent DVT but I'm not aware of any evidence of benefit when treating an established event. There are rare reports of pulmonary embolism following the application of SCDs in patients with asymptomatic DVTs. I don't think this constitutes an absolute contraindication, but in the absenc...
How would you manage a patient with SLE that has a remote history of positive anti-phospholipid antibodies with a current DVT and now completely negative APLs?
Assuming the reliability of the lab report indicating negative antiphospholipid antibodies (APL) and the absence of any other manifestations as per the latest APLS guidelines, I generally would not factor a distant history of APL positivity when determining the management of this patient.While the f...
What are your management strategies for malignant pericardial effusion with a high risk of spontaneous hemorrhage, particularly in patients requiring anticoagulation for chronic atrial fibrillation?
We have many patients with malignant pericardial effusion who tolerate anticoagulation for DVT/PE/afib. In those patients, when AC is restarted (for example after pericardiocentesis), close monitoring with serial echo in a few days would be performed to see if effusion reaccumulates faster. Also, th...
Does the presence of osteoporosis change the extent of workup that should be performed for an older patient with otherwise serologically low-risk MGUS?
In brief - no, it shouldn't. While some previous studies have suggested that patients with MGUS are more likely to develop osteoporosis than those who don't, this is often related to confounders when MGUS is picked up clinically - in other words, patients with comorbidities that prompt a doctor to l...
How do you determine when to use a maintenance regimen vs continuous 3-drug regimen in a transplant-ineligible MM patient after response to first line therapy?
After completing initial therapy (which may or may not include high dose melphalan and auto SCT), I typically use maintenance lenalidomide. I consider “dual maintenance,” which is combining lenalidomide and a proteasome inhibitor, for patients with high risk FISH: t(4;14), t(14;16), and del17p. 1q g...
For patients with multiple myeloma, when using Lenalidomide or Pomalidomide, how do you approach dose adjustment based on patient tolerance?
In general, my approach is to try to keep patients on the intended dose of an IMiD for as long as they can tolerate it (within reason). I think early dose reductions can be avoided by dedicated supportive care. For rashes, using antihistamines and topical corticosteroids can help. For diarrhea, imod...
What initial workup do you perform when there is a concern for porphyria?
This is a terrific question. But a broad question. Porphyria refers to a defect in heme biosynthesis leading to the accumulation of porphyrins and porphyrin precursors. We should remember that there are three general categories of porphyria based on clinical manifestations: acute hepatic porphyria (...
What is the anticoagulation recommendation for a chronic DVT?
Simply having a chronic DVT is not an indication for anticoagulation. In general, acute provoked VTE requires a minimum of 3 months of anticoagulation. For an unprovoked VTE, there are scoring systems that guide towards limited duration vs long-term of anticoagulation. So it depends on where the fin...