Hematology Flashcards
What are risk factors for lymphoma?
- Infection: HIV, HBV, HCV, HTLV1, EBV, H. pylori.
- Immune: RA, Crohn’s celiac, sjogren’s, HIV, post-solid organ transplant.
- Family history.
What are the Ann-Arbor staging criteria for lymphoma?
I - one region of nodal involvement.
II - multiple areas of nodes on one side of diaphragm.
III - both sides of diaphragm.
IV - extranodal (including bone marrow) involvement.
When do you not use DOAC for VTE?
- GI, GU or intracranial malignancy
- BMI>40 or wt>120 kg
- Renal failure CrCl < 15
- APLA syndrome
- Pregnancy/breastfeeding
- High clot burden (extensive PE, post thrombolysis, iliofemoral DVT, submassive PE).
- Drug interactions
- Plt < 50
What are indications for warfarin for VTE?
Mechanical valvse (INR 2.5-3.5 mitral, 2-3 aortic)
APLA (INR 2-3)
ESRD
Breastfeeding (INR 2-3)
When should you treat distal DVT?
Severe symptoms Multiple deep veins involved Active cancer >= 5cm long Close to popliteal vein Progression
When should you treat superficial vein thrombosis?
- <= 3cm from saphenofemoral junction (treat for 3 months full dose)
- > 3cm from saphenofemoral junction and >= 5cm long (prophylaxis for 45 days)
- > 3cm from saphenofemoral junction + <5cm long - NSAIDs and monitor on serial U/S
* Consider treating all pregnant, past clots, severe symptoms.
How do you manage with recurrent VTE on anticoagulation?
Verify compliance, INR, consider malignancy
If on DOAC/VKA -> switch to LMWH x 1 mo.
If on LMWH -> increase dose by 25-33%
What are diagnostic tests for von willebrand disease?
- VWF Ag quantity
- Ristocetin cofactor (VWF activity)
- Factor VIII level (VWF protects FVIII)
aPTT can be normal, hence not a good screening test
What are the 3 types of VWF disease?
Type 1 - mild to mod. Quantitative deficiency (Low VWF Ag = Low VWF activity)
Type 2: Qualitative def (low to normal VWF Ag, VERY LOW VWF activity)
Type 3: NO VWF produced (very low factor VIII) - behaves like hemophilia A
When do you avoid DOACs in cancer-associated VTE?
- GI, GU, intracranial malignancy
- Nephrostomy tubes or mucosal abnormalities
- Concomitant antiplatelet therapy
- High clot burden - extensive PE, sub-massive PE, post-thrombolysis, iliofemoral DVT
When should you consider outpatient DVT prophylaxis in cancer patients?
Khorana score >1 (i.e. high risk ambulatory cancer patients) can be offered apixaban 2.5 mg bid or rivaroxaban 10 mg daily (ASCO)
How do you reverse warfarin?
INR>9 = hold and give vitK 2.5-5 mg po
INR 4.5-9 = hold and lower warfarin dose
Minor bleed = vit K and support
Major bleed = IV vit K and PCC 2000 units x 1
Which patients with PE can be discharged home
Stable, no bleeding, no liver/kidney disease, platelets>70, no RV strain (STD and TWI in V1-3) or elevated troponin, compliant and access to healthcare.
How do you treat VWF disease?
Acute bleeding/periop:
- can give DDAVP to increase VWF level (does not work in type 2 and 3)
- VWF and FVIII concentrate
- Cryoprecipitate (type 2 and 3)
What are treatment options for ITP?
Dex 40 x4 days or Pred 0.5-2mg/kg (pred>dex for preg) + IVIG
2nd line splenectomy, ritux, TPO-R agonist
Admit if new ITP and platelets<20
How do you treat TTP while awaiting PLEX?
- FFP 3-4 units then 1 unit q2h.
- Plt if life threatening bleed
- Prednisone 1mg/kg/d or Solumedrol IV 1g/day
- Folic acid 5mg OD
- ASA if trop rise
- DVT proph when Plt >50
How do you manage HIT?
- IV argatroban or SC fonda, danaparoid if pregnant.
- Add warfarin when plt>150 and stop initial tx when INR 2-3 for >5d
- Bilateral leg dopplers
- Treat for 1 month if no VTE, 3 months if VTE.
What is the indication of rasburicase over allopurinol?
AKI
Uric acid > 535 umol/L
No response to allopurinol
*Must not have G6PD Def
What are indications for irradiated blood products?
Prevent transfusion related GVHD:
T cell deficiency
Hodgkin’s lymphoma
Chemotherapy with purine antagonists
HSC transplant recipient (allogenic = life, autologous = 3 months)
What are indications for treatment for CLL?
Lyphadenopathy > 10cm or symptomatic Splenomegaly > 6cm below costomargin or symptomatic Progressive cytopenia/BM failure AIHA/ITP with poor steroid response Extranodal involvement
What is the diagnostic criteria for MGUS?
M spike < 30g/L AND
BM plasma cell < 10% AND
No end organ dmg or CRAB symptoms
What is the diagnostic criteria for smoldering myeloma?
M spike >= 30g/L or UPEP-spke >= 500mg/24hr AND/OR
BM plasma cell 10-60% AND
No end organ dmg or CRAB symptoms
What is the diagnostic criteria for multiple myeloma?
BM plasma cell >=10% or plasmacytoma AND either
End organ dmg (CRAB) OR one of
BM clonal plasma >=60%, focal lesions that are >=5mm on MRI, FLC raio >=100
What are risk factors in MGUS progression and how do they affect subsequent mgt?
- M protein >= 15g/L
- Non igG M protein
- FLC ratio <0.26 or >1.65
0/3 RF -> low risk MGUS, SPEP in 6 months then q2yr (no BM bx or bone imaging)
> =1/3 RF -> high risk MGUS: BM bx, skeletal survey, CT abdo if IgM
What are treatment options for MDS?
Low cytogenic risk: supportive, lenalidomide
High cytogenic risk: supportive, HSC txt, azacitadine
How do you treat polycythemia vera?
Low risk age <60 and no thrombosis
High risk age >=60 or thrombosis h
Everyone ASA 81mg, HCT <45% with phlebotomy
High risk add hydroxyurea or ruxolitinib if unable to tolerate
What are primary causes of TMA?
- TTP (low ADAMTS13)
- aHUS - complement-mediated
- HUS (Shiga)
- Drugs
What are secondary causes of TMA?
- Pre-eclampsia/HELLP
- Malignancy
- Infection
- Autoimmune - SRC, APLA, SLE, vasculitis
- Transplant
- Hypertensive emergency
- DIC
