56
Treatment
Table 8. Hematologic Toxicities
G3: Hgb <8.0 g/dL;
<4.9 mmol/L; <80 g/L;
transfusion indicated
• Permanently discontinue ICPi.
• Should use clinical judgment and consider admitting
the patient.
• Hematolog y consult.
• Prednisone 1–2 mg/kg/day (oral or IV equivalent
depending on symptoms/speed of development).
• Consider RBC transfusion per existing guidelines.
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).
• Should offer patients supplementation with folic acid
1 mg daily.
G4: Life-threatening
consequences; urgent
intervention indicated
• Permanently discontinue ICPi.
• Admit patient.
• Hematolog y consult.
• IV prednisone corticosteroids 1–2 mg/kg/day.
• If no improvement on or if worsening on
corticosteroids or severe symptoms on presentation,
initiate other immunosuppressive drugs, such as
rituximab, IVIG, cyclosporine, infliximab, MMF,
or ATG.
• RBC transfusion per existing guidelines. Discuss
with blood bank team prior to transfusions that a
patient with possible ICPi SAE is in the hospital.
Additional considerations:
• Monitor hemoglobin levels on a weekly basis until the steroid tapering process is
complete. Thereafter, less frequent testing is needed.
8.2 Acquired Thrombotic Thrombocytopenic Purpura (TTP)
Workup/Evaluation
• History with specific questions related to drug exposure (e.g., chemotherapy,
sirolimus, tacrolimus, oxymorphone, antibiotics, quinine)
• Hematolog y consult
• Physical exam, peripheral smear to check for schistocytes
• ADAMTS13 activity level and inhibitor titer
• LDH, haptoglobin, reticulocyte count, bilirubin, urinalysis to rule out other causes
• Prothrombin time, activated partial thromboplastin time, fibrinogen
• Blood group and antibody screen, direct antiglobulin test
• Consider CT/MRI brain, echocardiogram, electrocardiogram
• Cytomegalovirus serolog y
Note: this disorder is usually associated with severe drop in platelets and hemolysis/
anemia precipitously (microangiopathy)
(cont'd)
