Should monitoring guidelines and decision to treat for I⁠gM MGUS be different when caring for Jehovah's Witness patients?

A practicing Jehovah's Witness with diagnosed IgM monoclonal gammopathy of undetermined significance (MGUS) in 2014 was hospitalized within one year of her annual checkup. She had hyperviscosity syndrome with blurry vision and severe anemia but, due to religious beliefs, would not accept blood products. She was treated with therapeutic plasma exchange therapy with subjective improvement of her blurry vision, decrease in her serum viscosity, and improvement of her anemia. This bloodless medicine patient (BMP) had annual follow up per the Mayo Clinic Stratification System guidelines for her asymptomatic MGUS, as she fell into the intermediate-risk category given her age, laboratory values, and lack of symptoms. Due to the inability to provide proper rescue therapy with blood products in the event of anemia, we suggest adjusting the monitoring and surveillance interval for BMPs regardless of laboratory values. We suggest that BMPs undergo additional monitoring including iron and coagulation studies to preempt and prevent potential complications of symptomatic anemia, coagulopathy, and hyperviscosity syndrome. We recommend shortening the follow-up for these patients to every 3-6 months, as opposed to the standard follow-up that is recommended for IgM MGUS (typically ranging from 6-12 months). This would also drive earlier conversations about the risks and benefits of initiating earlier treatment in these patients, given their risks of complications if their MGUS progresses to malignancy.