How is Disseminated Intravascular Coagulation (DIC) managed?

Management of Disseminated Intravascular Coagulation (DIC)

The cornerstone of DIC management is treating the underlying cause, followed by supportive care with blood products for bleeding and appropriate anticoagulation based on the clinical presentation. 1

First-Line Approach

• Treat the underlying condition - This is the most important first step in managing DIC, especially in cancer-related DIC where early treatment of the malignancy can lead to resolution of coagulation abnormalities 1
• Regular clinical and laboratory monitoring to assess improvement or worsening, detect complications including organ failure, and ensure adequate treatment of the underlying condition 1
• Laboratory surveillance should include regular blood counts and clotting screens with fibrinogen and D-dimer measurements 1

Supportive Care for Bleeding

For patients with active bleeding or at high risk of bleeding:

• Platelet transfusion to maintain platelet count:

  • Above 50 × 10^9/L in actively bleeding patients 1
  • Above 30 × 10^9/L in APL patients at high risk of bleeding 1
  • Above 20 × 10^9/L in other cancer patients at high risk of bleeding 1

• Fresh frozen plasma (FFP) (15-30 mL/kg) for patients with active bleeding and prolonged PT/aPTT 1

  • Consider prothrombin complex concentrates if volume overload is a concern 1

• Cryoprecipitate or fibrinogen concentrate for severe hypofibrinogenemia (<1.5 g/L) that persists despite FFP replacement 1, 2

Anticoagulation Therapy

• Prophylactic anticoagulation is recommended in all cancer-related DIC patients except those with hyperfibrinolytic DIC or contraindications (platelet count <20 × 10^9/L or active bleeding) 1

• Therapeutic-dose anticoagulation should be used in patients who develop arterial or venous thrombosis 1

  • For cancer patients with solid tumors: LMWH at full dose for first month, then 75% of full dose for 5 months 1
  • For patients with hematologic malignancies: Consider treatment doses of LMWH with frequent monitoring of anti-Xa levels 1

• Heparin administration options (FDA-approved for treatment of acute and chronic consumptive coagulopathies/DIC) 3:

  • Deep subcutaneous injection: Initial 5,000 units IV followed by 10,000-20,000 units subcutaneously every 8-12 hours
  • Intermittent IV injection: Initial 10,000 units, then 5,000-10,000 units every 4-6 hours
  • Continuous IV infusion: Initial 5,000 units IV, then 20,000-40,000 units/24 hours

Special Considerations

• Antifibrinolytic agents (e.g., tranexamic acid) are generally not recommended in DIC 1, 2

  • Exception: May be considered in hyperfibrinolytic DIC with therapy-resistant bleeding 1

• Recombinant Factor VIIa is not recommended for routine use in cancer-related DIC due to thrombotic risks 1

• Complicated scenarios with limited evidence 1:

  • New thrombus with severe thrombocytopenia (<25-50 × 10^9/L): Consider:

    1. Platelet transfusions with therapeutic anticoagulation
    2. Intermediate-dose or prophylactic anticoagulation without transfusions
    3. No anticoagulation unless thrombus is in a critical location (e.g., pulmonary embolism)

  • Inferior vena cava filter: Only consider temporary filter in patients who cannot receive anticoagulation but have proximal lower limb thrombosis likely to embolize 1

Monitoring

• Laboratory parameters should be regularly monitored, with worsening parameters (e.g., 30% or higher drop in platelet count) considered diagnostic of subclinical DIC 1

• Bleeding risk assessment is crucial when considering anticoagulation, with contraindications including platelet count <20 × 10^9/L or active bleeding 1, 3

• Heparin contraindications include history of heparin-induced thrombocytopenia (HIT), known hypersensitivity to heparin or pork products, inability to perform suitable blood coagulation tests at appropriate intervals, and uncontrolled bleeding state (except when due to DIC) 3

Common Pitfalls to Avoid

• Delaying treatment of the underlying condition, which is the most effective way to resolve DIC 1

• Administering blood products based solely on laboratory results rather than clinical bleeding status 2

• Using antifibrinolytic agents routinely in DIC, which may increase thrombotic risk 1, 2

• Overlooking the dynamic nature of DIC, which requires repeated testing and clinical reassessment 1, 2