Hematology
Clinical discussions on blood disorders, coagulation, transfusion medicine, and hematologic malignancies.
Recent Discussions
In what scenarios do you use a chromogenic factor X assay in adjusting INR goals for patients on warfarin?
I do not use this method. It has been suggested that such assays be used in patients with lupus-type inhibitors who have significantly prolonged prothrombin times at baseline. In this setting, if the INR is "therapeutic," one would confirm an adequate warfarin effect if the factor X activity was in ...
What is your preferred 1L treatment for newly diagnosed Del(17p)/TP53 mutation, High-Risk CLL?
For patients with TN-CLL with TP53 aberration, the treatment options are usually based on patient factors. If a patient is a candidate for combination therapy, I prefer to treat them with uMRD-guided BTKi+BCL2i ± CD20 mAb. I only add a CD20 mAb to patients with no history of frequent infections and ...
Are there still clinical situations in which you deliberately treat patients with a DOAC besides apixaban?
Thank you for your question. Apixaban has been my preferred agent for a long time for patients requiring therapeutic anticoagulation.Apixaban’s lower bleeding risk was shown prior to and now has additional evidence to support this with the COBRRA trial. The risk is also ameliorated by the safety in ...
In a patient who has been receiving 1L Ibrutinib for TP53+ CLL for years with complete hematologic response but detectable MRD, is there any role to switch to the novel BTKi agents given better PFS?
There are a couple of features to this question that need comment. First, the goal of therapy with a single-agent BTKi, regardless of ibrutinib, acalabrutinib, zanubrutinib, or pirtobrutinib, is NOT to achieve undetectable MRD. Very few patients will achieve this milestone due to the drug's MOA. BTK...
Are there any alternative, hypofractionated RT courses for patients with DLBCL that can be used during the COVID-19 pandemic?
ILROG recently came out with guidelines pasted below: Synopsis of ILROG Recommendations for Administering Radiotherapy for Hematological Malignancies During Emergency Conditions of the COVID-19 Pandemic • We are facing an increased demand for RT to substitute or complement systemic therapy deemed i...
Would you consider using transdermal estrogen in a patient with “high risk” APLS patient on warfarin?
Given her clinical diagnosis of high-risk APS, I would first trial nonhormonal therapies or progesterone-only therapies for management of her post-menopausal symptoms. Current ACR guidance recommends against hormone replacement therapy in patients with APS on anticoagulation (Sammaritano et al., PMI...
Do you offer enasidenib with azacitadine in AML with an IDH2 mutation for patients ineligible for intensive induction chemotherapy?
I typically do not give enasidenib with azacitidine upfront for patients with AML with IDH2 mutation and ineligible for intensive induction chemotherapy. Based on the results of the VIALE-A study (DiNardo et al, NEJM 2020), I usually give venetoclax with azacitidine to those patients. In addition to...
Can aplastic anemia present with multiple infiltrative bone lesions, such as in the spine and pelvis?
It is exceedingly unlikely that such bone lesions are due to aplastic anemia. AA is the absence of hematopoiesis, so there is no mechanism for bone lesions to be present.
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 ...
Would you use routine PET scans after two cycles of R-CHOP to guide first-line treatment de-escalation in low-risk (aaIPI = 0) DLBCL patients?
This phase III trial suggests that in very low-risk limited-stage DLBCL (aaIPI = 0), patients who achieve a negative PET after two cycles of R-CHOP can safely receive only four total cycles instead of six, with similar 3-year PFS (92% vs 89%) and less toxicity. However, the results apply to a highly...