5 Things Hematologists and their Patients should Question

The American Society of Hematolgy (ASH) has released a list of evidenced-based recommendations as part of the “Choosing Wisely” initiative in collaboration with the American Board of Internal Medicine (ABIM) Foundation.  This is an effort to strike up conversation between patients and physicians about the necessity and potential risks (both to health AND wallet) involved with certain medical practices.

This list was developed with input from ASH members using the most current evidence about hematologic management and treatment options.

1.)  Do not transfuse more than the minimum number of red blood cell (RBC) units necessary to relieve symptoms of anemia or to return a patient to a safe hemoglobin range (7 to 8 g/dL in stable, non-cardiac, in-patients).

Instead, transfusion of the smallest effective dose of red blood cells is recommended as liberal transfusion strategies do not appear to improve outcomes when compared with restrictive ones.  Unnecessary transfusions drive up costs and expose patients to risk without any likelihood of benefit.

Specifically, clinicians are urged to “avoid the routine administration of 2 units of RBCs if 1 unit is sufficient and to use appropriate weight-based dosing of RBCs in children”.

2.) Don’t test for thrombophilia in adult patients with venous thromboembolism (VTE) occurring in the setting of major transient risk factors (surgery, trauma or prolonged immobility).

Thrombophilia testing is expensive and can harm a patient if the duration of anticoagulation is inappropriately prolonged or if patients are misdiagnosed as thrombophilic.  Testing for thrombophilia does not change the management of VTEs occurring in the setting of major transient VTE risk factors.

When a VTE presents itself in the setting of pregnancy, hormonal therapy, or when there is a strong family history combined with a major transient risk factor, thrombophylia testing is complex.  In these situations, both patients and clinicians are advised to consult with a VTE expert.

3.) Don’t use inferior vena cava (IVC) filters routinely in patients with acute VTE.

IVC filters are expensive, can cause harm, and don’t have solid evidentiary basis.  Retrievable filters are recommended over permanent filters with removal of the filter once risk for Pulmonary Embolism has been resolved and/or when anticoagulation can be safely resumed.

4.)  Don’t administer plasma or prothrombin complex concentrates for non-emergent reversal of vitamin K antagonists (i.e. outside of the setting of major bleeding, intracranial hemorrhage or anticipated emergent surgery).

The potentially serious harm to patients health and financial well-being is not worth the risk when a reversal of vitamin K antagonists is rarely seen.  In non-emergency situations, it is best to hold the vitamin K antagonist and/or by administering vitamin K.

5.) Limit surveillance computed tomography (CT) scans in asymptomatic patients following curative-intent treatment for aggressive lymphoma.

CT surveillance in patients that show no symptoms and are in remission from aggressive non-Hodgkin lymphoma may be harmful.  Physicians are encouraged to carefully consider the benefits of post-treatment CT scans against the potential harm of radiation exposure.  CT scans in asymptomatic patients more than 2 years beyond completion of treatment are rarely advisable.