What to do if fibrinogen is elevated?

Management of Elevated Fibrinogen Levels

Elevated fibrinogen levels require identification and treatment of the underlying cause while monitoring for potential thrombotic complications. The primary approach to managing elevated fibrinogen is to identify and treat the underlying condition causing the hyperfibrinogenemia rather than directly targeting the fibrinogen level itself. 1

Diagnostic Approach

• Confirm elevation with repeat testing if initial result is unexpected

• Evaluate for underlying causes:

  • Acute inflammation or infection
  • Chronic inflammatory conditions (e.g., rheumatoid arthritis)
  • Malignancy
  • Pregnancy
  • Liver disease
  • Genetic variants

• Additional testing to consider:

  • Complete blood count with differential
  • C-reactive protein and ESR
  • Liver function tests
  • Viscoelastic testing (TEG/ROTEM) if available 1

Treatment Strategy

Primary Approach: Treat Underlying Conditions

• Antimicrobials for infections
• Anti-inflammatory therapy for inflammatory conditions
• Oncology-guided treatment for malignancy
• Control cardiovascular risk factors 1

Lifestyle Modifications

• Smoking cessation (most effective lifestyle intervention for lowering fibrinogen)
• Weight reduction
• Stress management
• Increased physical activity
• Moderate alcohol consumption may result in small reductions 2

Medication Considerations

• No specific drugs are approved solely for fibrinogen reduction
• Some medications have fibrinogen-lowering effects as secondary benefits:
  • Fibrates (e.g., bezafibrate) - can reduce elevated fibrinogen by up to 40%
  • Ticlopidine - can reduce elevated fibrinogen by about 15% 2

Special Clinical Scenarios

Trauma and Bleeding

• In trauma patients, fibrinogen levels naturally rise to approximately 7 g/L after major trauma 3
• Use goal-directed therapy guided by standard laboratory coagulation values and/or viscoelastic monitoring (VEM) 3
• Elevated fibrinogen in a bleeding patient may indicate:
  • Bleeding not yet severe enough to deplete fibrinogen reserves
  • Pre-existing inflammatory condition causing hyperfibrinogenemia
  • Qualitative fibrinogen dysfunction despite adequate quantity 1

Cirrhosis

• In patients with cirrhosis, fibrinogen levels <100 mg/dL are associated with spontaneous and procedure-related bleeding
• For invasive procedures in cirrhosis patients, a fibrinogen threshold of >120 mg/dL is commonly used 3
• Cryoprecipitate or fibrinogen concentrate can be used to increase fibrinogen levels, with fibrinogen concentrate having advantages of standardized content and lower volume 3

Pregnancy

• In pregnancy with elevated fibrinogen and bleeding risk, maintain fibrinogen level ≥1.5 g/L
• During labor and delivery, maintain fibrinogen level ≥1.5 g/L in women with a bleeding phenotype 3

Thrombotic Risk Management

• Evaluate for additional thrombotic risk factors
• Consider thromboprophylaxis in high-risk patients:
  • Hospitalized patients
  • Immobilized patients
  • Post-surgical patients 1
• Balance any hemostatic therapy against risk of thrombosis

Monitoring

• Use viscoelastic monitoring (TEG/ROTEM) when available to guide treatment decisions
• Focus on functional assessment of clot formation rather than absolute fibrinogen levels 1
• Regular monitoring of inflammatory markers may help track response to treatment of underlying conditions

Common Pitfalls to Avoid

• Treating the fibrinogen level rather than the underlying cause
• Failing to consider thrombotic risk in patients with elevated fibrinogen
• Overlooking chronic inflammatory conditions as a cause of persistent elevation
• Not considering that elevated fibrinogen may be a marker rather than a mediator of vascular disease 4