Treatment for Disseminated Intravascular Coagulation (DIC)
The cornerstone of DIC treatment is addressing the underlying cause, complemented by supportive measures including blood product transfusions according to specific thresholds and, in selected cases, anticoagulation with heparin. 1
Underlying Cause Treatment
- Treatment of the underlying condition is the primary and most important strategy for managing DIC 2, 1
- Early recognition and prompt diagnosis are crucial for improving prognosis 1
- For cancer-associated DIC, appropriate treatment of the underlying malignancy is the first-line approach 2
- In acute promyelocytic leukemia (APL), early commencement of induction therapy leads to good resolution of DIC 2
Monitoring
- Regular monitoring of blood count and coagulation parameters is essential, including fibrinogen and D-dimer measurements 2, 1
- Frequency of monitoring can range from daily to monthly depending on the clinical situation 1
- A decrease of 30% or more in platelet count may be diagnostic of subclinical DIC even without clinical manifestations 2
- Coagulation tests should guide therapy for full-dose heparin treatment 3
Blood Product Support
Platelet Transfusion
- In patients with active bleeding: maintain platelet count above 50×10⁹/L 2, 1
- In high bleeding risk patients without active bleeding: transfuse if platelets <30×10⁹/L in APL or <20×10⁹/L in other cancers 2, 1
- Note that transfused platelets may have very short lifespan in DIC with vigorous coagulation activation 2
Plasma and Fibrinogen Replacement
- For active bleeding: administer 15-30 mL/kg of fresh frozen plasma (FFP) with careful clinical monitoring 2, 1
- If concerned about volume overload, consider prothrombin complex concentrates 2
- For persistent hypofibrinogenemia (<1.5 g/L) with active bleeding: administer two pools of cryoprecipitate or fibrinogen concentrate 2, 1
Anticoagulation
- Heparin is FDA-approved for treatment of acute and chronic consumptive coagulopathies (DIC) 3
- Anticoagulation is primarily indicated in DIC with predominant thrombotic manifestations 1
- For cancer-associated DIC (except hyperfibrinolytic type): prophylactic anticoagulation is recommended in the absence of contraindications 2, 1
- Therapeutic anticoagulation should be used in patients who develop arterial or venous thrombosis 2
- 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
- Contraindications for anticoagulation include platelet count <20×10⁹/L or active bleeding 2
Special Clinical Scenarios
For new thrombus in patients with severe thrombocytopenia (<25-50×10⁹/L), consider: 2
- Platelet transfusions with therapeutic anticoagulation
- Intermediate-dose or prophylactic anticoagulation without transfusions
- No anticoagulation unless the thrombus is in a critical location (e.g., pulmonary embolism)
Inferior vena cava filter placement should only be considered in patients who cannot be anticoagulated but have proximal lower limb thrombosis likely to embolize 2
Important Considerations
- Abnormal coagulation tests alone should not be considered an absolute contraindication for anticoagulation in the absence of bleeding 1
- The lifespan of transfused blood products may be very short in DIC with intense coagulation activation 2, 1
- Tranexamic acid and recombinant FVIIa are not recommended for routine use in cancer-related DIC 2
- Consider tranexamic acid only if therapy-resistant bleeding dominates in hyperfibrinolytic DIC 2
By following this approach to DIC management, focusing first on treating the underlying cause and then providing appropriate supportive care based on clinical presentation and laboratory parameters, patient outcomes can be optimized.