Benign Hematology Inquiry Types
Primum's benign hematology specialists guide community oncologists across a wide variety of clinical scenarios, including:
- Discussion of options for differential diagnosis for benign hematology cases
- Independent validation of hematology treatment for malignant cancer cases
- Brainstorming approaches to care for complicated DVT patients
- And many others
The following is an example of an inquiry discussed with Primum's benign hematology panel.
Case Example: Treatment recommendation for complicated case of immune thrombocytopenia (ITP)
- Community Oncologist: “I have an 82 year old female with no significant PMH [past medical history] with ITP. Her baseline counts in December 2021 showed thrombocytopenia with platelet count 62,000/l. WBC count normal 6.0, hemoglobin normal 12.8 g/dL. Later in January 2022, her platelet counts dropped to 32,000/l; WBC/Diff and Hg were normal. Work up for hepatitis, HIV, autoimmune conditions, B12/folate/iron and liver imaging were unremarkable. In May her Plt counts dropped to 27,000 with no bleeding. I started her on decadron 40 mg daily x 4; her plt count normalized within 4 days to 256,000/l and started dropping slowly after 3 weeks; I'm using another pulse cycle of decadron 40 mg/ daily for 4 days;. Bone marrow biopsy was not done. Pt did not require hospitalization. No bleeding symptoms. In this age group, how many cycles of steroid would you consider before switching to second line? Any preference for rituxmab vs promacta or Nplate?”
- Benign Hematologist Response: “I usually proceed to second line therapy if platelets drop within a month of the first pulse of steroids so it would be reasonable to consider second line now. Choice of second line therapy depends mostly on patient preference as there are no head to head comparisons between agents. For patients who do not want to be on a medication indefinitely rituximab is a good option. For patients who do not mind indefinite therapy I prefer TPO. Rituximab usually has good efficacy in steroid responsive patients and has a median duration of effect of about 18 months so can provide a period of time off therapy, though is does carry risk of anaphylaxis and PML. The safety profile of TPO agents is generally preferable to rituximab, they are very safe and well tolerated, but they do have to be taken indefinitely. The efficacy appears to be similar between the agents, I generally prefer an oral agent for ease of administration so avatrombopag or eltrombopag are options. Avatrombopag does not have a black box warning for liver toxicity and can be taken with food so may be preferable for ease of administration”
Connect with Benign Hematology Specialists on Primum
If you are uncertain about how to treat your next benign hematology patient, would like to double-check your diagnosis or treatment approach, or otherwise run a case by a benign hematologist, the specialists on Primum are available to connect.
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Sources:
[1] Ma, A., "Benign Hematology Isn't So Benign", ASH Clinical News Editor's Corner, July 2015
[2] Green, J, “Adult Nonmalignant Hematology is an Endangered Field That Merits Protection”, Oncology Live Vol 22/No 1, 21 January, 2021
