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

Treatment of Disseminated Intravascular Coagulation (DIC)

The cornerstone of DIC management is aggressive treatment of the underlying condition (sepsis, cancer, trauma, etc.), combined with supportive care using blood product transfusions at specific thresholds and, in selected cases, anticoagulation with heparin. 1, 2, 3

Immediate Priorities

1. Treat the Underlying Cause

• This is the single most important intervention and takes absolute priority. 4, 1, 2
• In cancer-related DIC, initiate definitive cancer therapy immediately (chemotherapy, surgery, radiation as appropriate). 4
• In sepsis-related DIC, administer appropriate antibiotics and source control. 5
• In acute promyelocytic leukemia, early initiation of all-trans retinoic acid achieves excellent DIC resolution. 2

2. Hemostatic Support with Blood Products

For patients with active bleeding:

• Maintain platelets >50×10⁹/L with platelet transfusions. 1, 2, 6
• Administer 15-30 mL/kg of fresh frozen plasma (FFP) to replace coagulation factors. 2, 6
• If fibrinogen remains <1.5 g/L despite FFP, give cryoprecipitate (2 units) or fibrinogen concentrate. 2, 6

For patients at high risk of bleeding but not actively bleeding:

• Transfuse platelets if <30×10⁹/L in acute promyelocytic leukemia or <20×10⁹/L in other cancers. 2
• Consider platelet transfusion if <50×10⁹/L and invasive procedure planned. 6
• Do not transfuse based solely on laboratory abnormalities in non-bleeding patients. 1, 6

Critical caveat: Transfused platelets and clotting factors may have very short half-lives in DIC with vigorous coagulation activation, requiring frequent reassessment. 2

Anticoagulation Strategy

When to Use Heparin

Heparin is FDA-approved for DIC and indicated in the following scenarios: 3

• Thrombosis-predominant DIC: arterial/venous thromboembolism, severe purpura fulminans with acral ischemia, or vascular skin infarction. 6
• Cancer-related DIC (non-hyperfibrinolytic): prophylactic anticoagulation recommended in all patients unless contraindicated. 4, 1
• Therapeutic-dose anticoagulation: required if arterial or venous thrombosis develops. 4, 1
• Critically ill non-bleeding patients: prophylactic doses for venous thromboembolism prevention. 6

Heparin Dosing Approach

For therapeutic anticoagulation in thrombotic DIC:

• Use unfractionated heparin (UFH) continuous infusion at weight-adjusted doses (e.g., 10 units/kg/hour) in high bleeding risk patients due to short half-life and reversibility. 6
• Low molecular weight heparin (LMWH) preferred in other cases. 2
• In solid tumor-associated thromboembolism: LMWH at therapeutic dose for 6 months (full dose first month, then 75% dose for 5 months) is superior to warfarin. 2

Contraindications to heparin:

• Active bleeding (unless thrombosis is life-threatening). 2
• Platelets <20×10⁹/L. 2
• Hyperfibrinolytic DIC (see below). 4, 2

Important principle: Coagulation test abnormalities alone should not be considered an absolute contraindication to anticoagulation in the absence of active bleeding. 2

Special Considerations for Hyperfibrinolytic DIC

Avoid routine anticoagulation in hyperfibrinolytic DIC. 4, 2

Tranexamic Acid Use

• Routine use of tranexamic acid is strongly contraindicated in DIC due to increased thrombotic risk. 4, 1
• Never use in non-hyperfibrinolytic DIC as it may worsen outcomes. 1
• Only consider tranexamic acid in hyperfibrinolytic DIC with therapy-resistant bleeding that dominates the clinical picture. 4, 1
• Confirm hyperfibrinolysis with APTEM testing (thromboelastometry) before administering. 1
• Dosing: 10-15 mg/kg loading dose followed by 1-5 mg/kg/hour infusion. 1
• Alternative dosing: 1 g every 8 hours. 6

Recombinant Factor VIIa

• Not recommended due to lack of randomized controlled trial evidence and definite thrombotic risks. 4

Monitoring Requirements

Regular surveillance is essential to assess treatment response and detect complications: 4, 1

• Monitor complete blood count and coagulation tests (PT, aPTT, fibrinogen, D-dimer). 1, 2
• Check platelet count, hematocrit, and stool occult blood periodically throughout treatment. 3
• Frequency varies from daily in acute DIC to monthly in chronic compensated DIC. 2
• A ≥30% decrease in platelet count may indicate subclinical DIC. 2
• For continuous IV heparin: check aPTT at baseline, every 4 hours initially, then at appropriate intervals (target aPTT 1.5-2 times control). 3

Complex Clinical Scenarios

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

Three possible approaches exist: 4

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

IVC Filter Placement

• Only consider temporary filter in patients who cannot be anticoagulated but have proximal lower limb thrombosis likely to embolize. 4
• Avoid in other situations as filters can further activate coagulation. 4

Additional Therapies (Limited Evidence)

Recombinant Activated Protein C

• Consider in severe sepsis with DIC (24 mcg/kg/hour continuous infusion for 4 days). 6
• Contraindicated in high bleeding risk patients and platelet counts <30×10⁹/L. 6

Antithrombin Concentrate

• Not recommended based on lack of prospective randomized controlled trial evidence showing benefit on clinically relevant endpoints. 6