What is the treatment for hypofibrinogenemia?

Treatment for Hypofibrinogenemia

For patients with hypofibrinogenemia and significant bleeding, treatment with fibrinogen concentrate (3-4g) or cryoprecipitate (15-20 units in a 70kg adult) is recommended when plasma fibrinogen levels are below 1.5 g/L. 1

Assessment of Fibrinogen Levels

Before initiating treatment, it's crucial to determine the severity of hypofibrinogenemia:

• Measure plasma fibrinogen levels using the Clauss method
• Consider viscoelastic testing (thromboelastometry/ROTEM) if available, particularly in trauma settings
• Note that in the presence of artificial colloids like HES, the Clauss method may overestimate fibrinogen concentration 1

Treatment Options

1. Fibrinogen Concentrate

• Initial dose: 3-4g for adults 1
• Advantages:
  • Higher fibrinogen concentration
  • Lower volume
  • More consistent dosing compared to cryoprecipitate 2
  • Reduced risk of viral transmission
  • Accurate dosing 3

2. Cryoprecipitate

• Initial dose: 15-20 single donor units in a 70kg adult (approximately equivalent to 50 mg/kg) 1
• Each unit contains approximately 7.5 × 10¹⁰ platelets 1
• More variable in fibrinogen concentration compared to concentrate 2

Target Fibrinogen Levels

The target fibrinogen level depends on the clinical scenario:

• Major trauma with bleeding: Maintain fibrinogen ≥1.5 g/L 1
• Pregnancy-related conditions:
  • During pregnancy: ≥1.0 g/L 1
  • During labor/delivery: ≥1.5 g/L 1
  • For vaginal bleeding or placental abruption: ≥1.5 g/L 1

Monitoring and Follow-up

• Repeat doses should be guided by laboratory assessment of fibrinogen levels or viscoelastic monitoring 1
• In trauma settings, monitor fibrinogen levels regularly during active bleeding
• For congenital disorders requiring ongoing treatment, weekly monitoring initially, then monthly 1

Special Considerations

Trauma Patients

• Fibrinogen is often the first coagulation factor to critically decrease during massive blood loss 1, 2
• Early aggressive correction of hypofibrinogenemia may contribute to better outcomes 1
• Consider adding antifibrinolytic agents like tranexamic acid in bleeding trauma patients 1

Congenital Fibrinogen Disorders

• For afibrinogenemia and severe hypofibrinogenemia, regular replacement therapy may be needed 1
• During pregnancy, target trough fibrinogen levels of ≥1 g/L throughout pregnancy 1

Clinical Pitfalls to Avoid

• Delayed treatment: Fibrinogen is often the first coagulation factor to reach critical levels during hemorrhage 2
• Inadequate dosing: Underdosing may fail to achieve hemostasis
• Overreliance on laboratory values: In emergency situations, treatment may need to be initiated before laboratory results are available
• Failure to consider thrombotic risk: In patients with history of thrombosis, balance fibrinogen replacement with thromboprophylaxis 1

The evidence supporting fibrinogen replacement comes primarily from observational studies and expert consensus, with limited high-quality randomized controlled trials 4. However, the available evidence consistently suggests that fibrinogen replacement improves laboratory measures of coagulation and may reduce bleeding and transfusion requirements in patients with acquired hypofibrinogenemia 5, 4.