← HaemAcademyAll issuesGet it by email
haemacademy.orgIssue 1Monday 2 November 2026Literature from 1-31 October 2026

HaemAcademy Monthly

A monthly digest for haematology trainees and clinicians. Benign haematology, thrombosis and haemostasis come first: new guidelines, practice-changing trials and papers relevant at the bedside. Malignant haematology is summarised briefly for completeness.

In this issue. Two major ASH guidelines in benign haematology: immune thrombocytopenia, which moves first-line treatment beyond steroids alone, and iron deficiency diagnosis, which raises the ferritin threshold to 30 ng/mL. Also a mitapivat phase 3 trial in sickle cell disease, rilzabrutinib in warm AIHA and ITP, a large paediatric AIHA cohort, and in thrombosis a meta-analysis of thrombophilia and recurrent VTE, ISTH guidance on DIC in pregnancy and long-term emicizumab registry data. Malignant haematology follows in brief. Each entry is tagged by how far it should change practice.

Top three Read these first

Blood Advances · ASH Guideline

ASH 2026 ITP guideline: add rituximab or a TPO-RA to corticosteroids first-line, and use a TPO-RA second-line

Blood Advances · ASH Guideline

ASH 2026 iron deficiency diagnosis guideline: use a serum ferritin threshold of 30 ng/mL in adults, menstruating and pregnant people

Lancet · Phase 3 RCT

Mitapivat raises haemoglobin in sickle cell disease (41% vs 3% responders) but does not significantly reduce pain crises

Guidelines Benign haematology and thrombosis

Blood Advances · ASH GuidelineUpdates guidance

ASH 2026 ITP guideline: add rituximab or a TPO-RA to corticosteroids first-line, and use a TPO-RA second-line

Cuker A, et al. American Society of Hematology 2026 guidelines for immune thrombocytopenia: initial and second-line therapy for adults with primary ITP. Blood Adv. 2026 Oct 27;10(20):7076-7097. DOI 10.1182/bloodadvances.2026021269. PMID 42617047. Editorial: Mathew C, Zumberg M. 2026 ASH ITP guidelines: rethinking therapy. Blood Adv. 2026 Oct 27;10(20):7174-7176. DOI 10.1182/bloodadvances.2026022152. PMID 42895772.

A focused update of the 2019 ASH ITP guidelines for adults with primary ITP (not covering diagnosis, pregnancy or children), by a multidisciplinary panel including two patient representatives; evidence to 19 July 2025, GRADE methods. Initial therapy: suggest rituximab plus corticosteroids, or a TPO-RA plus corticosteroids (with or without IVIG), rather than mycophenolate plus steroids or steroids alone (conditional, low certainty). If neither rituximab nor a TPO-RA is available, steroids alone are suggested over mycophenolate plus steroids. Steroids should be limited to 6 weeks, or a short course of up to 2 weeks used while confirming the diagnosis. Second line: a TPO-RA is recommended (strong, moderate certainty) or rituximab suggested (conditional, low certainty); rituximab may suit patients who want to avoid long-term medication. Where both are unsuitable or declined, a BTK inhibitor, mycophenolate or SYK inhibitor is suggested (conditional, very low certainty). Good practice statements: delay splenectomy for at least a year where feasible, vaccinate at least 2 weeks beforehand, counsel on lifelong sepsis and thrombosis risk, and use shared decision-making when switching TPO-RAs while avoiding treatment gaps. The panel placed higher value on patient-important outcomes than on platelet count.

Impact on practice. This is the most important benign haematology publication of the month. It moves the default for newly diagnosed adults away from steroids alone, but the first-line recommendations are conditional and rest on low-certainty evidence, so local access, licensing and patient preference will decide uptake. Teams should review ITP pathways, steroid duration limits and funding for first-line rituximab or TPO-RA. The newer second-line options (BTK and SYK inhibitors) carry only very-low-certainty support. Based on the full text of the guideline.

Blood Advances · ASH GuidelineUpdates guidance

ASH 2026 iron deficiency diagnosis guideline: use a serum ferritin threshold of 30 ng/mL in adults, menstruating and pregnant people

Powers JM, Lim MY, et al. American Society of Hematology 2026 guidelines for diagnosis of iron deficiency. Blood Adv. 2026;10(21):7353-7374 (issue dated 10 Nov 2026; available online ahead of that date, exact online date not confirmed). DOI 10.1182/bloodadvances.2025015950.

Five GRADE-based recommendations from a multidisciplinary panel including one patient representative, with evidence to July 2025. Children aged 9 months to 4 years: suggest a ferritin threshold of 20 ng/mL or below rather than 12 (conditional, low certainty). Adults other than menstruating or pregnant people: suggest 30 ng/mL or below rather than 15 (conditional, low certainty). Menstruating people: suggest 30 ng/mL or below and suggest against 15 (conditional, low certainty). Pregnancy: suggest 30 ng/mL or below, and recommend against 15 (strong, low certainty). Adults with anaemia of inflammation: suggest ferritin plus transferrin saturation rather than ferritin alone (conditional, very low certainty). The guideline asks clinicians to diagnose iron deficiency whether or not anaemia is present, and calls for more screening in high-risk groups.

Impact on practice. This raises the ferritin cut-off most laboratories use, so more patients will be labelled iron deficient, particularly women of reproductive age and in pregnancy. Primary care and laboratory reference ranges are the practical issue: check whether local reporting still flags only values of 15 or below. All recommendations are conditional except the pregnancy statement and rest on low-certainty evidence. Based on the full text.

J Thromb Haemost · ISTH SSC CommunicationConfirms practice

ISTH registry of DIC in pregnancy: placental abruption and uterine atony are the leading causes

Erez O, et al. Disseminated intravascular coagulopathy in pregnancy: lessons from an international registry of the International Society for Thrombosis and Hemostasis: communication from the SSC of the ISTH. J Thromb Haemost. 2026 Oct;24(10):3784-3796 (epub 26 Jun 2026). DOI 10.1016/j.jtha.2026.06.030. PMID 42362026.

Registry from two ISTH committees collected data from 2018 to 2024: 148 entries from 13 countries, 104 with clinical and laboratory data. Placental abruption was the leading cause of ante- and intrapartum DIC, particularly with stillbirth. Uterine atony was the leading postpartum cause, especially during or after caesarean section. Abnormally implanted placenta is an increasing contributor. Abruption was the leading associated complication in high-income countries and pre-eclampsia in low- and middle-income countries. Women with placental-mediated complications had a lower median pregnancy-specific DIC score.

Impact on practice. A descriptive registry communication, not a graded guideline. It reinforces that DIC in pregnancy is usually obstetric-trigger driven, so treating the cause (delivery, uterotonics, haemorrhage control) remains the priority, with haematology support for product replacement. Useful for obstetric haemorrhage protocols; it does not change practice.

Benign haematology ITP, red cells, haemolysis, sickle cell

Lancet Haematology · Phase 2bHypothesis-generating

Rilzabrutinib achieves a 64% haemoglobin response in relapsed or steroid-dependent warm autoimmune haemolytic anaemia

Cooper N, et al. Rilzabrutinib, an oral Bruton tyrosine kinase inhibitor, in patients with warm autoimmune haemolytic anaemia: a prospective, single-arm, multicentre, phase 2b safety and clinical activity study (LUMINA 2). Lancet Haematol. 2026 Oct;13(10):e698-e709. DOI 10.1016/S2352-3026(26)00218-8. PMID 42822477.

22 adults with relapsed, refractory or steroid-dependent wAIHA (primary or SLE-associated) took oral rilzabrutinib 400 mg twice daily. Overall haemoglobin response by week 24 was 64% (14/22; 95% CI 41-83), including 14% complete response. Durable haemoglobin response in part B was 80% (12/15). Treatment-related adverse events in 45% of part A patients (nausea 14%, diarrhoea 9%); no deaths and no discontinuations for adverse events. Funded by Sanofi.

Impact on practice. Encouraging for a disease with few licensed options beyond steroids, rituximab and splenectomy. It is a small single-arm study, so it does not change practice, but it adds a plausible oral option for relapsed wAIHA ahead of randomised data.

Lancet Haematology · Phase 3 (open-label period)No change to practice

Rilzabrutinib in ITP: stable platelet response in 23% during the 28-week open-label period of LUNA3

Kuter DJ, et al. Clinical activity and safety of rilzabrutinib in patients with previously treated immune thrombocytopenia (LUNA3 open-label period). Lancet Haematol. 2026 Oct;13(10):e710-e721. DOI 10.1016/S2352-3026(26)00193-6. PMID 42753771.

Of 202 adults randomised (2:1 rilzabrutinib 400 mg twice daily vs placebo), 180 entered the open-label period (115 from the rilzabrutinib arm, 65 from placebo). Stable platelet response (a secondary endpoint) was seen in 46 of 198 exposed patients (23%), with 22% durable response among those switching from placebo. Treatment-related adverse events occurred in 26%, mostly grade 1-2 diarrhoea and nausea; treatment-related grade 3 events in 2%; no deaths. Funded by Sanofi.

Impact on practice. This reports the open-label phase, not the randomised primary endpoint, so it is supportive safety and durability data rather than a decision point. It does not change practice. Read it alongside the double-blind results before positioning BTK inhibition in the ITP pathway.

Lancet · Phase 3 RCTHypothesis-generating

Mitapivat raises haemoglobin in sickle cell disease (41% vs 3% responders) but does not significantly reduce pain crises

Andemariam B, et al. Efficacy and safety of mitapivat in patients with sickle cell disease (RISE UP): a phase 3, double-blind, global, randomised, placebo-controlled trial. Lancet. 2026 Oct 24;408(10565):1705-1716. DOI 10.1016/S0140-6736(26)01480-7. PMID 42913682.

207 patients over 16 with anaemia and recurrent pain crises were randomised 2:1 to mitapivat 100 mg twice daily (n=138) or placebo (n=69). Haemoglobin response 41% vs 3% (adjusted difference 38%, 95% CI 29-47; p<0.0001). Annualised pain crisis rate 2.6 vs 3.1 (p=0.1213, not significant). Serious adverse events 20% vs 29%. Funded by Agios; open-label extension ongoing.

Impact on practice. A positive haematological result and a negative key clinical endpoint. It does not show that mitapivat prevents vaso-occlusive crises, so it should not replace hydroxycarbamide or other disease-modifying options on this evidence. Watch for the extension data and regulatory view.

Blood Advances · Multicentre cohortUpdates guidance

Paediatric AIHA: nearly one in five children has an inborn error of immunity, and 42% relapse

Harris EM, et al. Pediatric autoimmune hemolytic anemia is associated with a high incidence of underlying immune disorders. Blood Adv. 2026;10(19):6346-6358 (online 23 Sept 2026; issue 13 Oct). DOI 10.1182/bloodadvances.2026020023. Commentary: Chonat S, Desai NJ. Blood Adv. 2026;10(19):6454-6455.

399 children from 15 centres. Most had a secondary diagnosis: Evans syndrome in 37%, other autoimmunity in 22% and an inborn error of immunity in 18%. Of those tested, 82% had abnormal functional immune results, and genetic testing found a pathogenic variant in 32% of those tested (31% were tested). Recurrent AIHA occurred in 42% and was linked to Evans syndrome (OR 4.85), inborn errors of immunity (OR 3.88) and other autoimmunity (OR 3.29). With a median 4.9 years of follow-up, 28% of warm AIHA cases still had active disease on treatment, and 10 children died, all with a secondary diagnosis.

Impact on practice. The practical message is to do a broad immune evaluation in every child with AIHA, including immunoglobulins, complement and a low threshold for genetic testing, rather than treating it as an isolated haemolytic problem. Retrospective data with variable testing, so rates may be inflated by selective testing. The authors call for paediatric AIHA guidelines, which do not yet exist.

Lancet Haematology · Retrospective cohort (REACH)Confirms practice

Hydroxyurea does not increase infections in African children with sickle cell anaemia; non-malarial infections fall at maximum tolerated dose

Williams TN, et al. Incidence of clinically diagnosed infections in children with sickle cell anaemia treated with oral hydroxyurea (REACH). Lancet Haematol. 2026 Nov;13(11):e789-e799 (epub 7 Oct 2026). DOI 10.1016/S2352-3026(26)00246-2. PMID 42843398.

606 children aged 1-10 in Angola, DR Congo, Kenya and Uganda started hydroxyurea; 5,493 infections were recorded over 5,638 person-years. Non-malarial infections: adjusted IRR 0.81 (95% CI 0.67-0.98) at fixed dose and 0.51 (0.43-0.61) at maximum tolerated dose versus screening. Grade 3 or higher infections: IRR 0.48 (0.32-0.73) at maximum tolerated dose. Funded by NHLBI.

Impact on practice. Reassuring data that support using hydroxyurea in settings with high infection burden. It is a retrospective analysis within a trial without a concurrent control group, so it confirms current practice rather than changing it.

Thrombosis & haemostasis VTE, anticoagulation, bleeding disorders

Blood Advances · Systematic review and meta-analysisUpdates guidance

Thrombophilia and recurrent VTE after stopping anticoagulation: antiphospholipid syndrome, antithrombin deficiency and homozygous factor V Leiden carry a two- to threefold risk

Vrotniakaite-Bajerciene K, et al. Recurrent VTE in patients with thrombophilia after stopping anticoagulation: a systematic review and meta-analysis. Blood Adv. 2026;10(19):6331-6345 (online 23 Sept 2026; issue 13 Oct). DOI 10.1182/bloodadvances.2026020623. Commentary: Kreuziger LB, Houghton DE. Blood Adv. 2026;10(19):6452-6453. DOI 10.1182/bloodadvances.2026021420.

51 studies and 34,623 patients (33.5% with unprovoked index VTE). Antiphospholipid syndrome, antithrombin deficiency, homozygous factor V Leiden and compound heterozygous FVL/prothrombin G20210A were associated with roughly a two- to threefold higher risk of recurrent VTE after stopping anticoagulation; heterozygous FVL or prothrombin mutation carried about a 1.5-fold risk. Protein C and S deficiency data were inconclusive. Heterogeneity and certainty were mostly moderate. The relative increase looked similar after provoked and unprovoked events.

Impact on practice. This supports testing selectively, in people where a high-risk thrombophilia would change the decision to extend anticoagulation, rather than broad panels. It does not overturn the ASH 2023 advice to test only when the result changes management, and the authors themselves say routine testing is not yet shown to help. Relative risks are pooled study-level estimates, so apply them alongside bleeding risk and D-dimer or prediction scores. Based on the full abstract and discussion.

Blood Advances · Registry cohortConfirms practice

Emicizumab in the Canadian Bleeding Disorders Registry: mean bleed rate fell from 1.00 to 0.47 with sustained control up to 5 years

Iorio A, et al. Long-term experience with emicizumab in people with hemophilia A in the Canadian Bleeding Disorders Registry. Blood Adv. 2026;10(19):6862-6872 (13 Oct 2026). DOI 10.1182/bloodadvances.2025019430. Commentary: Hermans C. Blood Adv. 2026;10(19):6860-6861.

710 people with haemophilia A received at least one dose of emicizumab (2018 to Dec 2023); 76% had more than a year of exposure. Over a median follow-up of 549 days, 62% had no recorded bleeds. Mean annualised bleed rate fell from 1.00 to 0.47 (rate ratio 0.47, 95% CI 0.41 to 0.55). There were 34 adverse events including 2 thrombotic events, one possibly related to previous bypassing-agent use and associated with a central venous access device.

Impact on practice. This adds routine-care data that agree with the pivotal trials, with no new safety signal. It is registry data without a control group, and bleeds are self-reported, so it supports current practice rather than changing it. Useful for centres reviewing local emicizumab outcomes or discussing options with families.

J Thromb Haemost · Safety databaseConfirms practice

Emicizumab: 13 years of safety data show no new thrombotic signal; events cluster with high-dose aPCC

Kelsch C, et al. Emicizumab prophylaxis in people with haemophilia A: summary of over 13 years of safety data on thromboembolic events and thrombotic microangiopathy. J Thromb Haemost. 2026; online ahead of print 26 Oct. DOI 10.1016/j.jtha.2026.10.014. PMID 42933658.

Pooled analysis of the Roche Emicizumab Global Safety Database (June 2012 to August 2025): 165 thromboembolic events and thrombotic microangiopathies in 138 people with haemophilia A. Two thromboembolic events and all five TMAs were linked to concomitant activated prothrombin complex concentrate at more than 100 U/kg/24 h for at least 24 hours. In emicizumab trials the thromboembolic event rate was 0.36 per 100 person-years (95% CI 0.16-0.68) against a background rate of 0.52 (95% CI 0.40-0.69). The authors report no new safety concerns.

Impact on practice. Confirms existing advice: avoid prolonged high-dose aPCC with emicizumab. About 41% of those with events had pre-existing cardiovascular or thrombotic risk factors, which matters for older patients. Manufacturer-sourced database, so reporting bias is possible.

J Thromb Haemost · Surveillance (EUHASS)Confirms practice

Thrombosis with factor concentrates in haemophilia is rare: fewer than 1 event per 1,000 patient-years; fibrinogen concentrate stands out

Makris M, et al. Thrombotic rates in individuals with inherited bleeding disorders treated with concentrate or bispecific antibody: fifteen-year EUHASS data. J Thromb Haemost. 2026; online ahead of print 3 Oct. DOI 10.1016/j.jtha.2026.09.035. PMID 42829087.

EUHASS surveillance across 95 centres in 27 countries (October 2008 to December 2023) recorded 204 thrombotic events within 30 days of product administration over 209,842 treatment-years. Rates per 1,000 patient-years: plasma-derived FVIII 1.10; standard half-life recombinant FVIII 0.70; extended half-life FVIII 0.52; emicizumab 0.92; fibrinogen concentrate 11.56. The authors conclude FVIII and FIX concentrate rates are below 1.0 per 1,000 patient-years.

Impact on practice. Reassuring for routine prophylaxis and for ageing patients with haemophilia, and it confirms current practice. The high rate with fibrinogen concentrate is a reminder to consider thrombotic risk factors when using it. Surveillance data are not randomised, so comparisons between products should be cautious.

J Thromb Haemost · CohortConfirms practice

Suspicion-based cancer screening after DVT misses very little: negative predictive value 98.2%

Appelboom Y, et al. Suspicion-based screening for occult malignancy in lower-extremity venous thrombosis: a real-world cohort study. J Thromb Haemost. 2026 Oct;24(10):3669-3678 (epub 10 Jul 2026). DOI 10.1016/j.jtha.2026.06.044. PMID 42431315.

Retrospective review of 1,285 patients with suspected DVT (258 DVT, 179 superficial vein thrombosis, 848 controls), median follow-up 5 years. First-year malignancy incidence 6.2% (DVT), 2.2% (SVT) and 2.3% (controls). Additional diagnostics were done in 57.8%, 18.4% and 9.2% (P<0.001). Among DVT patients who had no additional testing, 1-year malignancy was 0.8%. Negative predictive value of suspicion-based screening was 98.2% for DVT.

Impact on practice. Supports a restrictive, symptom-guided approach to looking for cancer after unprovoked DVT, in line with current UK guidance such as NICE NG158. Single-centre, retrospective, and does not change practice.

J Thromb Haemost · Systematic reviewNo change to practice

Low-dose aspirin in JAK2-positive MPN: about 40% fewer thrombotic events but roughly 2.5-fold more bleeding, on low-certainty evidence

Vrotniakaite-Bajerciene K, et al. Incidence of thrombosis and bleeding in patients with JAK2-positive myeloproliferative neoplasms receiving low-dose aspirin: a systematic review and meta-analysis. J Thromb Haemost. 2026; online ahead of print 17 Oct. DOI 10.1016/j.jtha.2026.09.044. PMID 42892330.

3 randomised trials and 7 observational studies (1,760 patients on aspirin, 367 not). Pooled thrombosis incidence 2.72 per 100 person-years (95% CI 1.59-4.65); aspirin vs no aspirin IRR 0.59 (95% CI 0.40-0.86). Pooled bleeding incidence 1.97 per 100 person-years (95% CI 1.06-3.65); IRR 2.43 (95% CI 1.15-5.11). Heterogeneity was high (I2 about 90%) and GRADE certainty was low.

Impact on practice. Does not change practice. It supports an individualised decision on aspirin in JAK2-positive MPN, weighing thrombotic risk against bleeding risk, rather than reflex prescribing. The evidence is low certainty and mostly observational.

Res Pract Thromb Haemost · Systematic reviewNo change to practice

Haemophilia B prophylaxis: pooled treated bleeding rate is still about 2 per year, lower in children and with extended half-life products

Lindsley K, et al. Bleeding events in people with hemophilia B on prophylactic factor IX treatment: a systematic review and meta-analysis. Res Pract Thromb Haemost. 2026 Sep 9;10(7):106954 (October 2026 issue). DOI 10.1016/j.rpth.2026.106954. PMID 42910129.

24 clinical trials and 53 observational studies of people with haemophilia B without inhibitors on prophylactic factor IX. Pooled treated annualised bleeding rate was 2.23 (95% CI 1.52-3.27) in 13 trials and 2.08 (95% CI 1.62-2.66) in 48 observational studies. Rates were generally lower in patients under 12 than in older patients, and with extended half-life than with standard half-life products. The authors note that many patients still have two or more bleeds a year, and that inconsistent ABR definitions add heterogeneity.

Impact on practice. Confirms that conventional factor IX prophylaxis leaves residual bleeding for many adults, which is the context for non-factor and gene therapy discussions. It does not change practice by itself.

Res Pract Thromb Haemost · Retrospective cohortHypothesis-generating

Buffer-positive serotonin release assay in HIT is linked to higher 30-day mortality (47.4% vs 17.1%) in a single-centre study

Rungjirajittranon T, et al. A buffer-positive serotonin release assay pattern is associated with increased mortality in HIT: a retrospective cohort study. Res Pract Thromb Haemost. 2026 Sep 28;10(7):106995 (October 2026 issue). DOI 10.1016/j.rpth.2026.106995. PMID 42959281.

207 HIT-positive patients followed for 30 days; 17 (8.2%) had a buffer-positive pattern. Thrombosis was similar (64.7% vs 50.2%; p=0.28), platelet recovery was slower (9.0 vs 5.0 days; p=0.03), and 30-day cumulative incidence of death was 47.4% vs 17.1% (adjusted HR 2.74; p=0.03). The authors call the findings hypothesis-generating, because platelet-rich plasma was used, and say confirmation with the classical washed-platelet assay is needed.

Impact on practice. Hypothesis-generating only: 17 patients, one centre, a non-standard assay method. It does not change HIT management, but it is a signal to watch if your lab reports buffer controls.

Res Pract Thromb Haemost · Claims-based studyNo change to practice

Second-line ITP in Korea: splenectomy vs TPO-RA after steroids, with longer time to next treatment on TPO-RA but a higher VTE rate

Lim HJ, et al. Treatment patterns and safety outcomes after splenectomy or thrombopoietin receptor agonists as second-line therapy for immune thrombocytopenia: Korean claims-based study. Res Pract Thromb Haemost. 2026 Sep 29;10(7):106992 (October 2026 issue). DOI 10.1016/j.rpth.2026.106992. PMID 42927077.

Retrospective national claims data (2002-2021) with propensity matching: 447 patients had splenectomy and 57 a TPO-RA without prior splenectomy. Median time to next treatment was 5.80 vs 3.03 months, with curves diverging after 24 months in favour of the TPO-RA group. Pneumococcal infection occurred in 3.1% after splenectomy and none with TPO-RA. VTE occurred in 10.5% vs 15.7%, with a shorter time to VTE in the TPO-RA group. The authors caution that residual confounding limits interpretation.

Impact on practice. Retrospective and unbalanced (57 vs 447), so it does not change practice. Read together with the new ASH ITP guideline, it illustrates the trade-offs between splenectomy and TPO-RA, including thrombotic risk.

J Thromb Haemost · RegistryHypothesis-generating

Edoxaban in CTEPH: low 5-year clinical-worsening and bleeding rates in a Japanese registry

Hosokawa K, et al. Long-term real-world effectiveness and safety of edoxaban in chronic thromboembolic pulmonary hypertension: a nationwide registry study. J Thromb Haemost. 2026 Oct;24(10):3564-3577 (epub 18 Jun 2026). DOI 10.1016/j.jtha.2026.06.012. PMID 42315026.

CTEPH AC Registry, 408 patients on edoxaban at registration, median follow-up 552 days. Cumulative incidence of the composite morbidity/mortality endpoint was 4.7% at 1 year, 10.0% at 3 years and 14.1% at 5 years. Clinically relevant bleeding was 3.2%, 4.8% and 5.6% at the same points; major bleeding 2.4% at 5 years; symptomatic VTE 1.5% at 5 years. Results were consistent across reperfusion history, WHO functional class, edoxaban dose and renal function.

Impact on practice. Supports edoxaban as a workable option in CTEPH, but there is no comparator arm and the population is Japanese, so it does not change practice. It is hypothesis-generating for DOAC use where warfarin has been the default.

Thrombosis and Haemostasis · Prespecified trial analysisHypothesis-generating

AF patients with older drug-eluting stents: NOAC alone bleeds less than NOAC plus clopidogrel regardless of stent age

Jin IT, et al. Impact of stent age on antithrombotic strategy for atrial fibrillation in patients with drug-eluting stents (ADAPT AF-DES). Thromb Haemost. 2026; online ahead of print 21 Oct. DOI 10.1055/a-2977-5632. PMID 42906622.

Prespecified analysis comparing NOAC monotherapy with NOAC plus clopidogrel by stent age: remote PCI (stent older than 2 years, n=577) and intermediate PCI (1-2 years, n=383). No significant interaction between strategy and stent age for 1-year net adverse clinical events. NOAC monotherapy had less major or clinically relevant non-major bleeding in both groups. A significant interaction for ischaemic outcomes disappeared when stent age was modelled continuously.

Impact on practice. Consistent with de-escalating to NOAC alone in stable patients with older stents. As a subgroup analysis it is hypothesis-generating; decisions should rest on the main trial result and cardiology input.

General clinical medicine Cardiology and medicine

Eur Heart J · ESC GuidelineUpdates guidance

2026 ESC Guidelines for the management of heart failure are published in the 9 October issue

Kober L, et al. 2026 ESC Guidelines for the management of heart failure. Eur Heart J. 2026 Oct 9;47(38):5346-5457. DOI 10.1093/eurheartj/ehag100. PMID 42661420.

PubMed lists no abstract for this document. The record covers heart failure phenotypes, staging, aetiology, pharmacotherapy, device therapy (CRT, ICD) and advanced heart failure. Because the abstract was not available, no recommendations are summarised here.

Impact on practice. A full ESC guideline that every physician managing heart failure should read in full text. Check the sections on comorbidities, including anaemia and iron status, before updating local pathways; those details were not reviewed for this issue.

NEJM · Phase 3 RCTNo change to practice

Milvexian after acute coronary syndrome: no reduction in cardiovascular events and no excess major bleeding; trial stopped for futility

Gibson CM, et al. (LIBREXIA ACS). Milvexian with antiplatelet therapy after acute coronary syndrome event. N Engl J Med. 2026 Oct 22;395(16):1575-1584. DOI 10.1056/NEJMoa2608717. PMID 42670965.

14,194 patients enrolled within 7 days of an ACS were randomised to milvexian 25 mg twice daily or placebo on top of standard antiplatelet therapy. Stopped for futility at interim analysis (556 events). Primary outcome (cardiovascular death, MI or ischaemic stroke) 5.4% vs 5.1%; HR 1.05 (95% CI 0.91-1.21; p=0.50). BARC 3c or 5 bleeding 0.3% in both arms.

Impact on practice. Negative for factor XIa inhibition in this setting and no change to ACS care. For haematologists, the safety signal is neutral; the indication-specific trials of factor XI inhibitors in atrial fibrillation and venous thromboembolism remain the ones to follow.

NEJM · Phase 3 RCTUpdates guidance

In stable left-sided endocarditis, response-tailored antibiotic duration gives more antibiotic-free days but more relapses

Bundgaard H, et al. (POET II). Response-tailored or standard-duration antibiotic treatment for infective endocarditis. N Engl J Med. 2026 Oct 22;395(16):1600-1609. DOI 10.1056/NEJMoa2607887. PMID 42663314.

508 stable adults with left-sided endocarditis (S. aureus, E. faecalis or streptococci) were randomised after 2-4 weeks of therapy to response-tailored treatment (n=255) or standard 4-6 weeks (n=253). Days alive without antibiotics within 6 months: 183 vs 169 (difference 13 days; 95% CI 12-13). Composite of death, unplanned surgery or embolic events: 8.2% vs 10.7% (difference -2.4 points; 95% CI -7.7 to 2.7), meeting non-inferiority. Relapse 5.1% vs 1.6% (p=0.04).

Impact on practice. Supports shortening antibiotics in carefully selected, clinically stable patients with close follow-up, although relapse was more frequent. Relevant to haematology teams managing bacteraemia and device- or valve-related infection in neutropenic or transplant patients, where the trial population does not apply directly.

Malignant haematology Brief notes, for completeness

BJH · GuidelineUpdates guidance

BSH updates its primary mediastinal B-cell lymphoma guideline: PET-adapted radiotherapy, dose-intensive chemoimmunotherapy

Osborne W, et al. (BSH Committee). The diagnosis and management of primary mediastinal B-cell lymphoma: a British Society for Haematology guideline. Br J Haematol. 2026 Oct;209(4):1505-1517 (epub 23 Aug 2026). DOI 10.1111/bjh.70768. PMID 42634099.

The most useful change for the multidisciplinary meeting is a clear, written basis for omitting radiotherapy after a complete metabolic response and a defined pathway for Deauville 4-5 residual disease. Teams still giving routine consolidation radiotherapy should review local protocols. This summary is based on the abstract; check the full text for regimen-level detail.

Blood Advances · ASH GuidelineUpdates guidance

ASH 2026 myelofibrosis guideline: 10 recommendations on prognostic testing, JAK inhibition, anaemia, transplant timing, antiplatelets and chelation

Stein BL, et al. American Society of Hematology 2026 guidelines for the management of myelofibrosis in adults. Blood Adv. 2026 Oct 14; online ahead of print. DOI 10.1182/bloodadvances.2026021650. PMID 42873117.

Useful for anaemia management and antiplatelet decisions, which are areas of frequent uncertainty in MPN clinics. The evidence search ended in January 2025, so check whether newer data, such as the navitoclax trial reported this month, are reflected. Review the full text for the recommendation grades.

NEJM · Phase 3 RCTLikely practice-changing

Chemotherapy-free ponatinib plus blinatumomab beats imatinib plus chemotherapy in adult Ph-positive ALL (24-month EFS 86% vs 67%)

Chiaretti S, et al. Ponatinib-blinatumomab or imatinib-chemotherapy for adult Ph-positive ALL. N Engl J Med. 2026 Oct 15;395(15):1483-1494. DOI 10.1056/NEJMoa2606208. PMID 42874102.

This is the strongest evidence yet for a chemotherapy-free frontline approach in Ph-positive ALL and will push services to adopt ponatinib plus blinatumomab where drugs are accessible. Caveats: follow-up is under two years, the overall survival difference is small so far (90% vs 85%), and the role of transplant in MRD-negative responders is still being defined. Expect this to change first-line discussions now and funding decisions soon.

Lancet Haematology · Phase 3 RCTHypothesis-generating

Felzartamab added to lenalidomide-dexamethasone lengthens PFS in relapsed myeloma (18.9 vs 10.4 months) in a Chinese phase 3 trial

He H, et al. Felzartamab plus lenalidomide-dexamethasone versus lenalidomide-dexamethasone for relapsed or refractory multiple myeloma: an open-label, parallel-controlled, randomised, phase 3 trial. Lancet Haematol. 2026 Oct;13(10):e722-e736. DOI 10.1016/S2352-3026(26)00223-1. PMID 42822478.

This confirms that adding an anti-CD38 antibody to lenalidomide-dexamethasone improves PFS, which is already established with daratumumab and isatuximab. The trial is limited to an Asian population, has no head-to-head comparison with existing anti-CD38 regimens, and shows more infection and treatment-related deaths. It does not change practice in settings with access to approved anti-CD38 combinations.

Blood · Phase 3 RCTNo change to practice

Navitoclax plus ruxolitinib doubles spleen response in untreated myelofibrosis but does not improve symptoms

Pemmaraju N, et al. TRANSFORM-1 phase 3 study: efficacy and safety of navitoclax plus ruxolitinib in patients with untreated myelofibrosis. Blood. 2026 Oct 15;148(16):2029-2042. DOI 10.1182/blood.2025032360. PMID 42378247.

A clear spleen-volume benefit but no symptom benefit, with substantial thrombocytopenia. Without an overall survival or symptom signal, this does not change practice. It is relevant for patients in trials and for debates about whether spleen response is the right endpoint.

Blood · Phase 2Hypothesis-generating

Tagraxofusp, azacitidine and venetoclax produce 88% composite remission in untreated BPDCN

Lane AA, et al. Tagraxofusp, azacitidine, and venetoclax for blastic plasmacytoid dendritic cell neoplasm. Blood. 2026 Oct 29;148(18):2229-2238. DOI 10.1182/blood.2026033906. PMID 42413008.

BPDCN is rare and evidence is limited to small series, so this is useful, practical data for a chemotherapy-light bridge to transplant in older patients. It is a single-arm study of 27 patients and does not change practice by itself, but it is reasonable to discuss at a specialist centre.

Blood · Phase 2Hypothesis-generating

Daratumumab alone gives rapid haematological responses in stage IIIb cardiac AL amyloidosis, but median survival is 10.4 months

Kastritis E, et al. A phase 2 trial of daratumumab monotherapy for patients with newly diagnosed cardiac stage IIIb AL amyloidosis. Blood. 2026 Oct 15;148(16):1973-1983. DOI 10.1182/blood.2025032897. PMID 42296025.

For the sickest AL amyloidosis patients, fast anti-CD38 therapy without upfront bortezomib looks feasible, and the early response is encouraging. Survival remains poor and the study is single-arm, so it supports current practice of starting daratumumab-based therapy early rather than introducing a new standard.

Blood · Phase 2 RCTHypothesis-generating

Adding midostaurin to venetoclax plus low-dose cytarabine does not improve remission in older AML; FLT3-ITD subgroup shows a signal

Chua CC, et al. A randomized phase 2 study combining midostaurin, low-dose cytarabine and venetoclax in newly diagnosed AML aged 60 years or older. Blood. 2026; online ahead of print 19 Oct. DOI 10.1182/blood.2026035389. PMID 42895904.

Neutral overall, so first-line venetoclax-based therapy for unfit older patients is unchanged. The FLT3-ITD result comes from 29 patients and needs confirmation before any off-label use.

Lancet Haematology · Phase 1Hypothesis-generating

MK-4002, a BCMA T-cell engager, shows activity in heavily pretreated myeloma; 12 mg chosen for further study

Madan S, et al. MK-4002, a B-cell maturation antigen-targeting T-cell engager, in relapsed or refractory multiple myeloma: an open-label, first-in-human, phase 1 study. Lancet Haematol. 2026 Nov;13(11):e822-e833 (epub 6 Oct 2026). DOI 10.1016/S2352-3026(26)00228-0. PMID 42838070.

Early-phase data in a crowded BCMA bispecific field. Not relevant to routine care yet, but a useful marker of what trial referral options may offer later. Funded by Harpoon Therapeutics, a Merck & Co. subsidiary.

Lancet Haematology · Phase 2 RCTHypothesis-generating

Ruxolitinib 1.5% cream reduces affected skin area in chronic cutaneous GVHD in a small intra-patient controlled trial

Markova A, et al. Topical ruxolitinib for chronic cutaneous graft-versus-host disease: a single-centre, randomised, double-blind, intra-patient-controlled phase 2 trial. Lancet Haematol. 2026 Oct;13(10):e737-e746. DOI 10.1016/S2352-3026(26)00201-2. PMID 42748944.

A proof of concept for a steroid-sparing topical option. Single-centre, 28 days, 24 patients, so it does not yet alter management, but it is relevant for patients who need to limit steroid exposure. Larger trials with longer follow-up are needed.

Also published Not summarised this month