Hematology
Clinical discussions on blood disorders, coagulation, transfusion medicine, and hematologic malignancies.
Recent Discussions
How would you approach secondary stroke prevention in an adult with Hemoglobin SC disease?
Stroke is less common in HbSC disease than it is in HbS homozygotes (Ohene-Frempong et al., PMID 9414296). Thus, there are no studies focused on primary or secondary stroke prevention in HbSC disease. Recent guidelines for stroke management were “silent” on stroke in HbSC disease (DeBaun et al., PMI...
How do you decide between systemic antiangiogenic therapies for HHT?
Pomalidomide was just recently published in NEJM (Al-Samkari et al., PMID 39292928) showing efficacy in improving epistaxis in patients with HHT. It has an advantage as it is an oral agent versus bevacizumab being an IV infusion. Bevacizumab, however, has previously shown efficacy in smaller studies...
In what situations would you consider ESAs in hospitalized patients with severe anemia for indications other than CKD or myelosuppressive chemotherapy (e.g., ACD, hemorrhage)?
In deciding on the risk-benefit of ESAs in patients with severe anemia due to bleeding and/or inflammatory disease, there are two considerations. The first is the severity of the anemia and consequently, the time to initial response. Using the standard dose of ESAs, it may take 8 to 12 weeks to achi...
How do you approach IVIG replacement for pediatric patients with low IgG during treatment for hematologic malignancies?
We monitor IgG levels at the beginning of each chemotherapy cycle for infants, for patients with Down syndrome, for those receiving blinatumomab, and for patients who are hypogammaglobulinemic with recurrent bacterial infections, and we replace when IgG levels are <400 mg/DL for down syndrome and <5...
For pediatric patients with localized diffuse large B-cell lymphoma being treated per COG ANHL 1131 in group B, do you feel it is necessary to complete all lumbar punctures with IT therapy?
For unresected group B/DLBL patients, most centers continue to give the IT therapy which included 9 prophylactic IT therapies. There is no published data that I am aware of reducing the IT dosing. We recently completed a pilot reducing the number of ITs to 5 by incorporating 2 doses of depocyt (whic...
What is your current approach to maintenance therapy in FLT3-mutant AML post allogeneic HCT?
I would offer maintenance with FLT3 inhibitor with gilteritinib (NCT02997202: MORPHO trial, not yet published), sorafenib (SORMAIN trial), or midostaurin (RADIUS trial), whichever agent is available. In my experience, gilteritinib appears to be the most tolerable. I suggest beginning maintenance as ...
How do you counsel sickle cell patients on the use of G-CSF to treat neutropenia from other causes, like malignancy?
G-CSF is contraindicated in sickle cell disease. There have been many case reports of severe complications, including death in patients with SCD receiving G-CSF. I would only use it in neutropenic sepsis with transfusion support to prevent vaso-occlusive complications and after a discussion about it...
Would you consider caplacizumab in a pregnant patient with iTTP?
As noted, caplacizumab was not studied in pregnancy (was an exclusion criteria) and is not approved in this setting.With that being said, as noted, caplacizumab use in pregnancy has been described in case reports (1, 2, 3) and in the post-partum setting (4). I would consider the use of caplacizumab ...
How often do you monitor AML patients after transplant for recurrence?
Assuming that your patient was transplanted in CR and there is no plan for maintenance treatment, we typically repeat BM A/Bx at D100, 6 and 12 months after alloSCT. We continue to follow PB myeloid R/D chimerism studies regularly after (q 2-3 months for the next 2 years), obviously with CBC. We do ...
What would be the main indications for opting for biosimilars over an original biologic, outside of insurance barriers?
A timely question, as we head to 2023! The only reason to use biosimilars is for the broad purpose of resource stewardship. There isn't a medical reason to prefer a biosimilar over a reference product (or vice versa), because if a product were found to have a significantly different therapeutic effe...