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

Treatment of Disseminated Intravascular Coagulation (DIC)

The cornerstone of DIC treatment is aggressive management of the underlying disease, combined with supportive care using blood product transfusions based on specific thresholds, and prophylactic anticoagulation with heparin in selected cases—particularly those with thrombotic phenotypes. 1, 2

Fundamental Treatment Principles

Treating the underlying condition is the single most critical intervention and takes absolute priority. 1, 2 This is exemplified by the excellent resolution of DIC in acute promyelocytic leukemia (APL) patients when induction therapy is started early 1. The prompt recognition of DIC is equally important, as emphasized by the International Society on Thrombosis and Haemostasis (ISTH) 1.

Blood Product Support for Active Bleeding

When patients present with active bleeding, specific transfusion thresholds must be followed:

Platelet Transfusion

• Maintain platelet count >50×10⁹/L in patients with active bleeding 1, 2
• For high bleeding risk without active bleeding (surgery, invasive procedures): transfuse if platelets <30×10⁹/L in APL or <20×10⁹/L in other cancers 1
• Critical caveat: The lifespan of transfused platelets may be extremely short in DIC with vigorous coagulation activation, requiring frequent monitoring and repeat transfusions 1

Fresh Frozen Plasma (FFP)

• Administer 15-30 mL/kg in actively bleeding patients 1, 2
• Monitor carefully for volume overload; if this is a concern, use prothrombin complex concentrates instead 1

Fibrinogen Replacement

• If fibrinogen remains <1.5 g/L despite FFP, transfuse two pools of cryoprecipitate or fibrinogen concentrate 1, 2

Anticoagulation Strategy

The decision to anticoagulate depends on the DIC phenotype:

Prophylactic Anticoagulation

Prophylactic anticoagulation is recommended in all patients with cancer-related DIC except those with hyperfibrinolytic DIC, provided there are no contraindications 1. Contraindications include:

• Platelet count <20×10⁹/L 1
• Active bleeding 1

Therapeutic Anticoagulation

Use therapeutic-dose anticoagulation in patients who develop arterial or venous thrombosis 1. Heparin (unfractionated or low-molecular-weight) is the agent of choice 1, 3.

Heparin Selection

• Prefer unfractionated heparin (UFH) in patients with high bleeding risk and renal failure due to its reversibility 2
• Prefer low-molecular-weight heparin (LMWH) in other cases 2
• Heparin is FDA-approved for treatment of acute and chronic consumptive coagulopathies (DIC) 3

Important Exception

Avoid heparin in hyperfibrinolytic DIC 1, 2. In therapy-resistant bleeding with hyperfibrinolytic DIC, tranexamic acid may be considered, though routine use is not recommended 1.

Monitoring Requirements

Regular monitoring of complete blood count and coagulation studies, including fibrinogen and D-dimer, is mandatory 1, 2. The frequency varies from daily to monthly depending on clinical severity 1, 2.

A 30% or greater drop in platelet count can be diagnostic of subclinical DIC even without clinical manifestations 1, 2. This is particularly important because a "normal" platelet count that has dropped significantly from a previously elevated level may be the only sign of DIC in some malignancy patients 1.

Agents NOT Recommended

Recombinant Factor VIIa and routine tranexamic acid are not recommended in cancer-related DIC 1. These agents carry thrombotic risks and lack evidence from randomized controlled trials 1.

Special Clinical Scenarios

New Thrombosis with Severe Thrombocytopenia (<25-50×10⁹/L)

Three management options exist 1:

1. Platelet transfusions plus therapeutic anticoagulation
2. Intermediate-dose or prophylactic anticoagulation without transfusions
3. No anticoagulation unless the thrombus location is critical (e.g., pulmonary embolism vs. deep vein thrombosis)

Inferior Vena Cava Filter

Only consider temporary filters in patients who cannot be anticoagulated but have proximal lower limb thrombosis likely to embolize 1. In other situations, filters can be deleterious by further activating the coagulation system 1.

Critical Pitfalls to Avoid

• Do not withhold anticoagulation based solely on abnormal coagulation tests in the absence of active bleeding 2
• Do not ignore a declining platelet trend even if the absolute count remains in the normal range 1
• Remember that PT/PTT may not be prolonged in cancer-associated DIC, especially subclinical forms 1
• Recognize that transfused blood products have very short half-lives in DIC with vigorous coagulation activation 1, 2