What is the treatment for Disseminated Intravascular Coagulation (DIC)?

Treatment of Disseminated Intravascular Coagulation (DIC)

The cornerstone of DIC management is treating the underlying cause, complemented by supportive measures including blood product transfusions and, in selected cases, anticoagulation with heparin. 1

Diagnosis and Monitoring

• Regular monitoring of complete blood count and coagulation tests (including fibrinogen and D-dimer) is essential, with frequency ranging from daily to monthly depending on clinical context 1
• A 30% or greater drop in platelet count may indicate subclinical DIC even without clinical manifestations 2
• Normal coagulation tests do not rule out DIC, as PT and PTT may not be prolonged in cancer-associated DIC, especially in subclinical forms 2

Treatment Algorithm

Step 1: Treat the Underlying Cause

• Addressing the primary condition (sepsis, malignancy, trauma, obstetric complications) is the most important intervention 1, 3
• Early treatment of the underlying disease is crucial for improving outcomes, as demonstrated in acute promyelocytic leukemia where prompt induction therapy leads to good resolution of DIC 2

Step 2: Supportive Blood Product Management

For patients with active bleeding:

• Maintain platelet count above 50×10⁹/L with platelet transfusions 2, 1
• Administer fresh frozen plasma (15-30 mL/kg) with careful clinical monitoring 2, 1
• For persistent hypofibrinogenemia (fibrinogen <1.5 g/L) despite other measures, administer two pools of cryoprecipitate or fibrinogen concentrate 2, 1
• Consider prothrombin complex concentrates if volume overload is a concern 2

For patients at high risk of bleeding without active hemorrhage:

• Transfuse platelets if count is <30×10⁹/L in acute promyelocytic leukemia or <20×10⁹/L in other cancers 2, 1
• Note that transfused platelets and fibrinogen may have very short lifespans in DIC with vigorous coagulation activation 2, 1

Step 3: Anticoagulation Therapy

• Heparin is indicated primarily in DIC with predominant thrombotic manifestations 1, 4
• For DIC associated with solid tumors: consider prophylactic heparin in the absence of contraindications (platelets <20×10⁹/L or active bleeding) 1
• In patients with high bleeding risk and renal failure: prefer unfractionated heparin due to its reversibility 1
• In other cases: low molecular weight heparin is preferred 1
• Avoid heparin in DIC with predominant hyperfibrinolysis 1
• Dosing for therapeutic anticoagulation with unfractionated heparin: initial dose of 10,000 units IV, followed by intermittent IV injections or continuous infusion adjusted based on aPTT (target 1.5-2 times normal) 4

Special Considerations

• Abnormal coagulation tests alone should not be considered an absolute contraindication to anticoagulation in the absence of bleeding 5
• In cancer-related DIC with thromboembolism: LMWH at therapeutic doses for 6 months (full dose for first month, then 75% dose for 5 months) is superior to warfarin 1
• Individualized supportive management based on underlying disease, presence of bleeding or thrombotic complications, and laboratory results is recommended given the limited evidence from randomized controlled trials 5

Common Pitfalls to Avoid

• Don't overlook decreasing platelet counts that remain within normal range, especially in cancer patients with initially high counts - a 30% drop may be the only sign of DIC 2
• Remember that transfused blood products may have very short lifespans in DIC with intense coagulation activation 2, 1
• Don't delay treatment of the underlying condition while managing the coagulopathy 1, 6
• Avoid antifibrinolytic therapy in patients with the organ failure type of DIC 7