What is the management and treatment of Disseminated Intravascular Coagulation (DIC)?

Management and Treatment of Disseminated Intravascular Coagulation (DIC)

The cornerstone of DIC management is treating the underlying condition, complemented with supportive measures including blood product transfusions according to specific thresholds and, in selected cases, anticoagulation with heparin. 1, 2

General Principles

• Treatment of the underlying condition (e.g., cancer, sepsis, trauma) is the fundamental first-line strategy for managing DIC 3, 1, 2
• Regular clinical and laboratory surveillance is essential to monitor disease progression and treatment response 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 Measures

• In patients with DIC and active bleeding: maintain platelets >50×10⁹/L 2, 4
• In high bleeding risk patients without active hemorrhage: transfuse if platelets <30×10⁹/L in acute promyelocytic leukemia (APL) or <20×10⁹/L in other cancer types 2
• The half-life of transfused platelets may be very short in DIC with vigorous coagulation activation 2
• In patients with DIC and 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 two units of cryoprecipitate or fibrinogen concentrate 2
• Avoid prophylactic transfusions based solely on laboratory values 4

Anticoagulation

• Heparin is indicated primarily in DIC forms with thrombotic predominance 2, 5
• In cancer-associated DIC: consider prophylactic anticoagulation in the absence of contraindications (platelets <20×10⁹/L or active bleeding) 3, 2
• In 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
• For therapeutic anticoagulation in DIC, the FDA-approved dosing is: initial dose of 5,000 units IV, followed by 20,000-40,000 units/24 hours in continuous infusion 5

Special Considerations for Cancer-Associated DIC

• Treatment of the underlying malignancy is fundamental 3, 2
• In APL, early initiation of induction therapy achieves good resolution of DIC 2
• In solid tumors with thromboembolic events: LMWH at therapeutic dose for 6 months (first month at full dose, 5 months at 75% dose) has proven superior to warfarin 2

Tranexamic Acid in DIC

• 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
• APTEM testing (thromboelastometric monitoring) should be used to confirm hyperfibrinolysis before administering tranexamic acid 1

Recombinant Factor VIIa

• The role of recombinant FVIIa in DIC management remains uncertain 3
• There are only occasional case reports of successful use, but no randomized controlled trials 3
• Thrombotic risks are definitely associated with this treatment 3
• Use of recombinant FVIIa cannot be recommended in DIC 3

Pitfalls and Caveats

• 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 blood products may be very short in DIC with intense coagulation activation 2
• In patients with new thrombus and severe thrombocytopenia (<25-50×10⁹/L), consider: (1) platelet transfusions and therapeutic anticoagulation, (2) intermediate-dose or prophylactic anticoagulation without transfusions, or (3) no anticoagulation unless the thrombus site is critical (e.g., pulmonary embolism) 3
• Temporary inferior vena cava filters should only be considered in patients who cannot be anticoagulated but have proximal lower limb thrombosis likely to embolize 3