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

Treatment for Disseminated Intravascular Coagulation (DIC)

The fundamental treatment of DIC is to aggressively treat the underlying disease process, supplemented by supportive transfusion therapy based on specific platelet and coagulation thresholds, with heparin anticoagulation reserved for predominantly thrombotic presentations. 1

Immediate Priorities

Treat the underlying condition first—this is the cornerstone of DIC management and takes precedence over all other interventions. 2, 1, 3 Early identification and treatment of the precipitating cause (sepsis, malignancy, obstetric complications, trauma) is crucial for survival. 4 In acute promyelocytic leukemia (APL), early initiation of all-trans retinoic acid (ATRA) achieves excellent resolution of DIC. 2, 5

Monitoring Requirements

• Perform regular monitoring of complete blood count and coagulation studies including fibrinogen and D-dimer. 2, 1
• Monitor at least daily in acute DIC, adjusting frequency from daily to monthly based on clinical severity. 2, 1, 3
• A 30% or greater drop in platelet count suggests subclinical DIC even without clinical bleeding. 2, 1

Platelet Transfusion Thresholds

In actively bleeding patients with DIC, maintain platelet count >50×10⁹/L. 2, 1, 4, 3, 6, 7

In non-bleeding patients at high risk for bleeding (surgery, invasive procedures), transfuse platelets if:

• <30×10⁹/L in APL 2, 1
• <20×10⁹/L in other cancers or non-malignant DIC 2, 1, 4, 3, 6, 7

Avoid prophylactic platelet transfusion in non-bleeding patients without high bleeding risk. 4, 6 The lifespan of transfused platelets may be very short in DIC with vigorous coagulation activation. 2, 1

Fresh Frozen Plasma (FFP) and Fibrinogen Replacement

In actively bleeding patients with prolonged PT/aPTT, administer FFP at 15-30 mL/kg. 2, 1, 4, 3, 6 Do not transfuse FFP based solely on laboratory abnormalities in non-bleeding patients. 6, 7

If volume overload is a concern, consider prothrombin complex concentrates, recognizing they only partially correct the defect as they contain selected factors rather than the global factor deficiency present in DIC. 2, 6

If fibrinogen remains <1.5 g/L despite FFP, administer two pools of cryoprecipitate or fibrinogen concentrate. 2, 1, 4, 6

Heparin Anticoagulation

Use therapeutic-dose heparin in DIC presentations where thrombosis predominates: arterial/venous thromboembolism, severe purpura fulminans with acral ischemia, or vascular skin infarction. 6

In cancer-associated DIC with solid tumors, use prophylactic-dose heparin (not therapeutic) unless contraindicated. 2, 1

Contraindications to heparin include:

• Active uncontrolled bleeding 3, 6
• Platelet count <20×10⁹/L 2, 1, 3, 6
• Hyperfibrinolytic DIC 1, 3

Choice of heparin formulation:

• Prefer unfractionated heparin (UFH) in cardiac surgery patients, high bleeding risk situations, or renal failure due to short half-life and reversibility with protamine. 1, 3, 8, 6
• Use low-molecular-weight heparin (LMWH) in other cases for prophylaxis. 2, 1, 7
• For therapeutic anticoagulation in cancer with thromboembolism, use LMWH at full dose for 1 month, then 75% dose for 5 months (superior to warfarin). 1

In critically ill non-bleeding DIC patients, provide thromboprophylaxis with prophylactic-dose heparin or LMWH. 6, 7

Special Considerations by Underlying Condition

Cancer-associated DIC:

• Treatment of the malignancy is fundamental. 2, 1
• More liberal use of blood products in APL due to high hemorrhagic death rates. 5
• Solid tumors have prothrombotic phenotype—use prophylactic heparin. 2, 1

Acute-on-chronic liver failure:

• Standard coagulation tests (INR) correlate poorly with bleeding risk. 4
• Admit to intensive care with early transplant center referral. 4
• Treat precipitating factors (infection, GI bleeding, hepatotoxic drugs). 4

Cardiac surgery:

• Identify and treat surgical trigger (bleeding requiring re-exploration, infection). 3
• UFH preferred due to reversibility. 3

Common Pitfalls to Avoid

• Do not transfuse blood products based solely on laboratory abnormalities without bleeding or high bleeding risk. 4, 6, 7
• Do not use antifibrinolytic agents (tranexamic acid) routinely—reserve only for primary hyperfibrinolytic DIC with severe bleeding. 3, 6
• Laboratory abnormalities alone are not absolute contraindications to anticoagulation in the absence of active bleeding. 1
• Recognize that transfused products have very short half-life in DIC with vigorous coagulation activation—repeated dosing may be necessary. 2, 1