COMMON HEMATOLOGY CONCERNS DISCLOSURES. No applicable financial disclosures Bryan Primary Care Conference Eric J Avery, MD October 13, 2018

Transcription

1 COMMON HEMATOLOGY CONCERNS 2018 Bryan Primary Care Conference Eric J Avery, MD October 13, 2018 DISCLOSURES No applicable financial disclosures 1

2 OBJECTIVES Overview of Cellular Hematology Case Reviews WBC RBC Platelets Coagulation Cascade Summary A QUICK REVIEW 2

3 LEUKOCYTES 77 yo with Leukocytosis Asymptomatic No B symptoms (fevers, chills, noc sweats) Still farming, upset that my appt is slowing harvest 3

4 BEST CONFIRMATORY TEST(S) A: BCR:ABL testing B: Flow cytometry for lymphocyte subset C: ESR, CRP, Procalcitonin, Blood cultures x2 D: Peripheral smear WORKUP? History Physical CBC (ALC >5000 x 3 months) Flow cytometry 4

5 ANEMIA 78yo Female with Fatigue No bleeding/bruising No blood donations/transfusions No CKD CHARACTERIZE THE ANEMIA History: Bleeding, bleeding, bleeding Is that really a GI bleed when they haven t pooped for a week? Meds Alcohol, obesity, liver Retics are bigger than normal RBC (severe hemolysis can be Macrocytic) Check the smear (well, ask path or heme to do that) LDH, bilirubin, haptoglobin (be careful), plasma hemoglobin, coombs (DAT), retic, ferritin, iron, TIBC, B12, folate, TSH, kidneys, etc 5

6 RBC DIFFERENTIAL Check MCV Microcytic (MCV <80) Normocytic (MCV ) Macrocytic (MCV >100) Hemolytic -Iron Deficient -Anemia of Chronic Dz -Thalassemia -Sideroblastic anemia -Lead poisoning -G6PD -Spherocytes -PK Defic -Sickle Cell -HbC dz -MAHA -Autoimmune HA NonHemolytic -Fe Defic -Anemia Chronic Dz -Anemia CKD -Aplastic Megaloblastic -B12 -Folate -Copper -Drug induced Non-Megalo -ETOH -Liver -Diamond- Blackfan RDW=RED CELL DISTRIBUTION WIDTH 6

7 IT S USUALLY NOT JUST ONE THING DON T JUST CHECK SERUM IRON To Clarify: I don t recommend B12/Folate for std eval of microcytosis 7

8 WHICH STATEMENT IS TRUE REGARDING IRON DEFICIENCY? A: Hepcidin increases iron absorption in the intestine B: Ferritin <15 is nearly 99% specific in making diagnosis of iron deficiency C: Iron deficiency in you patient should never be worked up for GI blood loss/malignancy D: Oral iron is best absorbed if given thrice daily TREATMENT OF IRON DEFICIENCY Oral Iron is the most cost effective option Once a day, every OTHER day is more effective than twice a day in some patients Lancet Hem vol 4, Issue 11, Pg , Nov 2017 They need to be on it for months after resolution IV iron for poor absorption, fast response, profound low levels Calculate the Fe deficiency (target Hgb-pt Hgb) *weight in kg*2.4 8

9 60 YO MALE AT ANNUAL EXAM Some Fatigue Working No new medical problems Up to date on immunizations Nonsmoker Benign exam 60 YO MALE AT ANNUAL EXAM 9

10 SPEP M Spike IMMUNOFIXATION IFE confirms the type of antibody or free light chain circulating 10

11 FREE LIGHT CHAINS As Cancerous Plasma B cells (myeloma cells) make more antibodies, they can also make extra free light chains. We can monitor those with a simple blood test. FLC assay may be more reliable than M-Protein spike WHICH IS NOT A TRUE STATEMENT? A: Myeloma diagnosis includes criteria for FLC ratio >100 or MRI showing bone lesion(s) B: CRAB criteria are obsolete C: Median overall survival of R-ISS III is over 40 months D: Skeletal surveys have significantly lower sensitivity than cross-sectional imaging E: 10 new treatment options FDA approved since

12 IMAGING FOR MYELOMA Skeletal survey was a mainstay for years Cross-sectional imaging is now standard of care Low dose CT STIR MRI PET/CT FYI ON PLATELETS 12

13 FYI, CONT. Death in 24% with platelet transfusion vs 17% with SOC Serious Events in the hospital in 42% with transfusion vs 29% with SOC COAGULATION CASCADE REVIEW PT T PT 13

14 COAGS If a screening PT/INR is being drawn, you need a PTT as well DOACS are slightly preferred over warfarin for new simple thromboses Proceed cautiously with age, GI bleeding, renal/liver issues, absorption, compliance, and cancer patients SUMMARY Absolute cell differential on CBC is very helpful % on differential aren t as reliable Oral iron absorbs best once a day, every other day Try a Mon, Wed, Fri schedule Cross-sectional imaging for plasma cell workup DOACs are safe, effective, and expensive Know which patient do/don t deserve the DOACs 14

15 REFERENCES m.png Iron absorption from oral iron supplements given on consecutive versus alternate days and as single morning doses versus twice-daily split dosing in iron-depleted women: two open-label, randomised controlled trials. Lancet Hem vol 4, Issue 11, Pg , Nov 2017 UpToDate website Imaging of Multiple Myeloma and Related Plasma Cell Dyscrasias. J Nucl Med July 1, 2012 vol. 53 no QUESTIONS? Nebraska Hematology Oncology Eric Avery, MD eavery@yourcancercare.com text or call 15