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

Treatment of Disseminated Intravascular Coagulation (DIC)

Treat the underlying disease immediately—this is the cornerstone of DIC management—while simultaneously providing supportive care with blood product transfusions based on specific thresholds and considering prophylactic anticoagulation in most cases except hyperfibrinolytic DIC. 1

Immediate Priorities

Treat the Underlying Cause

• Initiate disease-specific therapy without delay, as DIC resolution depends entirely on controlling the primary disorder 2, 3, 1
• For acute promyelocytic leukemia: start all-trans retinoic acid immediately, which achieves excellent DIC resolution 2, 1
• For sepsis-associated DIC: implement source control and appropriate antibiotics urgently 1
• For cancer-associated DIC: begin chemotherapy, surgery, or radiation as indicated 1
• For obstetrical complications, trauma, or other triggers: address the specific precipitating factor 4, 5

Monitor Coagulation Parameters

• Check complete blood count, PT/aPTT, fibrinogen, and D-dimer regularly—frequency ranges from daily in acute severe DIC to monthly in chronic stable cases 2, 1
• A 30% or greater drop in platelet count is diagnostic of subclinical DIC, even when absolute values remain normal 2, 3, 1
• Use the ISTH DIC scoring system (≥5 points indicates overt DIC) for objective diagnosis and monitoring 1, 6

Supportive Hemostatic Management

Platelet Transfusion Thresholds

• Active bleeding: maintain platelets >50×10⁹/L 2, 3, 1, 6
• High bleeding risk without active bleeding (surgery, invasive procedures):
  • Transfuse if platelets <30×10⁹/L in acute promyelocytic leukemia 2, 3
  • Transfuse if platelets <20×10⁹/L in other cancers 2, 3
• Do not transfuse prophylactically based solely on laboratory values in non-bleeding patients without high bleeding risk 7, 6

Plasma and Fibrinogen Replacement

• Active bleeding with prolonged PT/aPTT: administer 15-30 mL/kg fresh frozen plasma 2, 3, 1, 6
• Monitor clinically for volume overload; if this is a concern, use prothrombin complex concentrates instead 2
• Persistent fibrinogen <1.5 g/L despite FFP: give two pools of cryoprecipitate or fibrinogen concentrate 2, 3, 1, 6
• Critical caveat: transfused platelets and fibrinogen have very short lifespans in DIC with vigorous coagulation activation, so repeated dosing may be necessary 2, 3

Anticoagulation Strategy

Classify DIC Subtype First

The ISTH recognizes three distinct forms requiring different approaches 1:

Procoagulant DIC (thrombosis predominates):

• Common in pancreatic cancer and adenocarcinomas 1
• Presents with arterial ischemia, venous thromboembolism, or microvascular thrombosis 1
• Initiate prophylactic anticoagulation with heparin unless contraindicated 2, 1, 6

Hyperfibrinolytic DIC (bleeding predominates):

• Typical of acute promyelocytic leukemia and metastatic prostate cancer 1
• Presents with widespread bleeding from multiple sites 1
• Do NOT use heparin in this subtype—avoid anticoagulation 3, 6

Subclinical DIC:

• May progress to overt DIC 2, 1
• Consider prophylactic anticoagulation 1

Heparin Dosing Algorithm

For procoagulant DIC without active bleeding:

• First choice: low molecular weight heparin (LMWH) at prophylactic doses 1, 6
• Contraindications: platelets <20×10⁹/L or active bleeding 2, 3

For established thrombosis (arterial/venous thromboembolism, severe purpura fulminans, vascular skin infarction):

• Escalate to therapeutic-dose anticoagulation 1, 6
• If high bleeding risk exists, use continuous infusion unfractionated heparin (UFH) at weight-adjusted doses (e.g., 10 units/kg/h) due to short half-life and reversibility 6
• Do not necessarily aim for aPTT prolongation to 1.5-2.5 times control; monitor clinically for bleeding 6

For critically ill non-bleeding patients:

• Provide prophylactic-dose heparin or LMWH for venous thromboembolism prevention 6

FDA-approved indication: Heparin is specifically indicated for "treatment of acute and chronic consumptive coagulopathies (disseminated intravascular coagulation)" 8

Special Considerations

Cancer-Associated DIC

• In solid tumors with thromboembolic events: LMWH at therapeutic dose for 6 months (first month at full dose, subsequent 5 months at 75% dose) is superior to warfarin 3
• Warfarin is ineffective in chronic DIC 9
• Long-term subcutaneous heparin may be required if DIC persists due to non-regressing tumor 9

Sepsis-Associated DIC

• Consider recombinant human activated protein C (24 mcg/kg/h continuous infusion for 4 days) in severe sepsis with DIC 6
• Do not use if platelet count <30×10⁹/L or high bleeding risk 6
• Discontinue shortly before invasive procedures (half-life approximately 20 minutes) 6

Acute-on-Chronic Liver Failure

• Standard coagulation tests (INR) correlate poorly with bleeding risk in cirrhotic patients 7
• Early identification of precipitating factors (infections, GI bleeding, drug toxicity) is crucial 7
• Admit to intensive care or intermediate care units with early transplant center referral if appropriate 7

Agents NOT Recommended

Antithrombin concentrate:

• Cannot be recommended without further evidence from randomized controlled trials showing benefit on clinical endpoints 6

Antifibrinolytic agents (tranexamic acid):

• Generally contraindicated in DIC 6
• Exception: may consider lysine analogues (tranexamic acid 1 g every 8 hours) only in DIC characterized by primary hyperfibrinolytic state with severe bleeding 6

Extracorporeal liver support:

• No survival benefit demonstrated in acute-on-chronic liver failure with DIC 7

Critical Pitfalls to Avoid

• Do not delay treatment of the underlying disease—supportive measures alone will not resolve DIC 2, 3, 1
• Do not use heparin in hyperfibrinolytic DIC—this will worsen bleeding 3, 6
• Do not transfuse based solely on laboratory abnormalities—reserve transfusions for active bleeding or high bleeding risk situations 7, 6
• Do not assume standard half-lives for transfused products—consumption may be rapid, requiring frequent reassessment 2, 3
• Do not use intramuscular injections—frequent hematomas occur at injection sites 8