Management and Treatment of Disseminated Intravascular Coagulation (DIC)
The cornerstone of DIC management is treating the underlying condition (e.g., cancer, sepsis, trauma), complemented with supportive measures including transfusions of blood products according to specific thresholds and, in selected cases, anticoagulation with heparin. 1, 2
General Principles
- Treatment of the underlying disease is the first-line strategy for all forms of DIC 3, 1, 2
- Regular clinical and laboratory surveillance is essential to monitor disease progression, detect complications including organ failure, and ensure adequate treatment of the underlying condition 3, 1
- Early recognition and prompt diagnosis are crucial for improving prognosis 2
Laboratory Monitoring
- Regular monitoring of complete blood count and coagulation tests, including fibrinogen and D-dimer, is recommended 2
- Monitoring frequency may vary from daily to monthly depending on the clinical scenario 2
- A decrease of 30% or more in platelet count may be diagnostic of subclinical DIC 2
Hemostatic Support
Platelet Transfusion
- In patients with active bleeding: maintain platelets >50×10⁹/L 2, 4
- In high bleeding risk without active hemorrhage: transfuse if platelets <30×10⁹/L in acute promyelocytic leukemia or <20×10⁹/L in other cancers 2
- Be aware that transfused platelets may have a very short half-life in DIC with vigorous coagulation activation 2
Plasma and Fibrinogen Replacement
- In patients with active bleeding: administer 15-30 mL/kg of fresh frozen plasma (FFP) 2, 4
- In cases of active bleeding with persistently low fibrinogen (<1.5 g/L): administer cryoprecipitate or fibrinogen concentrate 2
- Avoid prophylactic transfusions based solely on laboratory values 4
Anticoagulation Therapy
- Heparin is indicated primarily in DIC forms with thrombotic predominance 2, 5
- In cancer-associated DIC: prophylactic anticoagulation is recommended in the absence of contraindications (platelets <20×10⁹/L or active bleeding) 3, 2
- For patients with high bleeding risk and renal failure: prefer unfractionated heparin (UFH) due to its reversibility 2
- In other cases: prefer low molecular weight heparin (LMWH) 2
- Avoid heparin in DIC with predominant hyperfibrinolysis 2
- Therapeutic-dose anticoagulation should be used in patients who develop arterial or venous thrombosis 3
Special Considerations
Cancer-Associated DIC
- Treatment of the underlying malignancy is fundamental 3, 2
- In acute promyelocytic leukemia, early initiation of induction therapy achieves good resolution of DIC 2
- In solid tumors with thromboembolic events: LMWH at therapeutic doses for 6 months (first month at full dose, 5 months at 75% dose) has proven superior to warfarin 2
Tranexamic Acid Use
- Routine use of tranexamic acid in DIC is strongly discouraged due to increased thrombotic risks 3, 1
- Non-hyperfibrinolytic forms of DIC should not be treated with tranexamic acid as it may worsen outcomes 3, 1
- Tranexamic acid may be considered only in hyperfibrinolytic DIC when therapy-resistant bleeding dominates the clinical picture 3, 1
Common Pitfalls and Warnings
- Abnormalities in coagulation tests alone should not be considered an absolute contraindication for anticoagulation in the absence of bleeding 2
- The half-life of transfused products may be very short in DIC with intense coagulation activation 2
- Recombinant FVIIa is not recommended in the management of cancer-related DIC due to thrombotic risks 3
- Inferior vena cava filters should only be considered in patients who cannot be anticoagulated but have proximal lower limb thrombosis likely to embolize; in other situations, filters can be deleterious by further activating the coagulation system 3