TRAINING and EDUCATION
You Make the Call
Each month in “You Make the Call,” we’ll pick a challenging clinical question
submitted through the Consult-a-Colleague program and post the expert’s
response. But, what would YOU do? We’ll also pose a submitted question
and ask you to send your responses. See how your answer matches up to the
experts in the next print issue.
This month, Alice J. Cohen, MD, advises on the choice of anticoagulation in a
patient who developed pulmonary embolism after knee surgery.
Clinical Dilemma:
A 28-year-old male patient underwent arthroscopic right knee surgery and received no anticoagulation after the knee
surgery. He then developed deep-vein thrombosis in his right lower extremity approximately two weeks after the
surgery. The orthopedic physician prescribed apixaban (10 mg taken orally), twice a day as an outpatient. After four
doses, the patient developed left chest pain and was found to have bilateral moderate pulmonary embolism. The patient
is now on intravenous heparin. Should this instance be considered anticoagulation failure? Do you have any treatment
recommendations for this patient?
Consult a Colleague
Through ASH
Consult a Colleague is a service for ASH
members that helps facilitate the exchange of information between hematologists and their peers. ASH members
can seek consultation on clinical cases
from qualified experts in 11 categories:
• Anemias
• Hematopoietic cell
transplantation
• Hemoglobinopathies
• Hemostasis/thrombosis
• Lymphomas
• Lymphoproliferative disorders
Experts Make the Call
• Leukemias
Alice J. Cohen, MD
Director, Division of Hematology/Oncology
Training Program Director, Hematology/Oncology
Director, Hemophilia and Thrombosis Treatment Center
Newark Beth Israel Medical Center
Newark, New Jersey
• Myeloproliferative Disorders
• Multiple myeloma & Waldenström
macgroglobulinemia
• Myelodysplastic Syndromes
• Thrombocytopenias
Assigned volunteers (“colleagues”) will
respond to inquiries within two business
days (either by email or phone).
Unfortunately, as a chest computed tomography (CT)
was not performed at baseline when the patient presented with deep-vein thrombosis, we do not know if
the pulmonary embolism occurred after the initiation
of apixaban treatment. I would say, if the patient has
received at least two doses of apixaban, he should have
been adequately anticoagulated. I would not want to
label this as a case of anticoagulation failure because we
did not have a baseline CT. However, as there are other
options for anticoagulation available such as warfarin, I
would recommend using an alternative anticoagulant in
this patient.
I would not select dabigatran in this instance because of the issues with renal clearance and no available
creatinine clearance.
Have a puzzling clinical dilemma?
Submit a question, and read more
about Consult-a-Colleague volunteers at
hematology.org/Clinicians/Consult.aspx
or scan the QR code.
DISCLAIMER: ASH does not recommend or endorse any specific tests, physicians, products, procedures, or opinions, and
disclaims any representation, warranty, or guaranty as to the same. Reliance on any information provided in this article is
solely at your own risk.
*If you have a request related to a
hematologic disorder not listed here, please
email your recommendation to ashconsult@
hematology.org so it can be considered for
addition in the future.
Next Month’s Clinical Dilemma:
A 52-year-old man with low-risk acute
promyelocytic leukemia (APL) presenting
with a white blood cell (WBC) count of
3,200 and a platelet count of 70,000 was
started on all-trans-retinoic acid (ATRA)
58
ASH Clinical News
+ arsenic trioxide. The patient experienced a rise in WBC count from 16,000
on day 12 to 25,000 on day 20 - despite
starting dexamethasone on day 15. The
patient experienced bilateral swelling in
the lower extremities with no effusion.
I am concerned about differentiation
syndrome and the continued rise in WBC
count, despite treatment with 10 mg
dexamethasone delivered every 12 hours.
Should ATRA be held until WBC
count improves, or should the patient be
started on idarubicin or another agent?
How would you respond? Email us at
[email protected].
July 2015