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

Treatment of Disseminated Intravascular Coagulation (DIC)

Treat the underlying disease immediately—this is the absolute cornerstone of DIC management, as all supportive measures will fail without addressing the root cause. 1, 2

Core Treatment Algorithm

Step 1: Identify and Treat the Underlying Condition

The primary intervention is aggressive treatment of the precipitating disorder, as DIC is always secondary to another disease process 1, 2:

• Sepsis-associated DIC: Initiate source control and appropriate antibiotics immediately 1
• Cancer-associated DIC: Begin chemotherapy, surgery, or radiation as indicated 1
• Acute promyelocytic leukemia: Start all-trans retinoic acid urgently, which achieves excellent DIC resolution 1, 2
• Obstetric complications, trauma, or other causes: Address the specific underlying pathology 3

Step 2: Classify the DIC Subtype

DIC presents in three distinct forms requiring different management approaches 1:

• Procoagulant DIC (thrombosis predominates): Common in pancreatic cancer and adenocarcinomas, presenting with arterial ischemia, venous thromboembolism, or microvascular thrombosis 1
• Hyperfibrinolytic DIC (bleeding predominates): Typical of acute promyelocytic leukemia and metastatic prostate cancer, with widespread bleeding from multiple sites 1
• Subclinical DIC: Laboratory markers of coagulation activation without obvious clinical manifestations 1

Step 3: Implement Supportive Hemostatic Measures

Only transfuse blood products in patients with active bleeding or those requiring invasive procedures—do not transfuse based solely on laboratory abnormalities 4:

Platelet Transfusion

• Active bleeding: Maintain platelet count >50×10⁹/L 1, 2, 4
• High bleeding risk without active hemorrhage: Transfuse if platelets <30×10⁹/L in acute promyelocytic leukemia or <20×10⁹/L in other cancers 2
• Non-bleeding patients: Prophylactic platelet transfusion is not recommended unless high bleeding risk is perceived 4

Critical caveat: Transfused platelets may have very short half-life in DIC with vigorous coagulation activation 2

Fresh Frozen Plasma (FFP)

• Active bleeding with prolonged PT/aPTT: Administer 15-30 mL/kg of FFP 1, 2, 4
• No evidence that FFP stimulates ongoing coagulation activation 4
• If fluid overload prevents FFP use, consider prothrombin complex concentrate (recognizing it only partially corrects the defect) 4

Fibrinogen Replacement

• Persistent fibrinogen <1.5 g/L despite FFP: Replace with cryoprecipitate (two units) or fibrinogen concentrate 1, 2, 4

Step 4: Anticoagulation Strategy

Initiate prophylactic anticoagulation with heparin in all patients EXCEPT those with hyperfibrinolytic DIC, unless contraindications exist 1, 5:

Prophylactic Anticoagulation

• First-line agent: Low molecular weight heparin (LMWH) for most patients 1
• Critically ill non-bleeding patients: Use prophylactic doses of heparin or LMWH for venous thromboembolism prevention 4
• Contraindications: Platelets <20×10⁹/L or active bleeding 2
• High bleeding risk with renal failure: Prefer unfractionated heparin for reversibility 2

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

Therapeutic Anticoagulation

• Thrombosis-predominant DIC: Use therapeutic-dose anticoagulation if arterial or venous thrombosis develops, severe purpura fulminans with acral ischemia, or vascular skin infarction 1, 4
• Continuous infusion unfractionated heparin: Consider weight-adjusted doses (10 units/kg/h) without necessarily prolonging aPTT to 1.5-2.5 times control, due to short half-life and reversibility 4
• Solid tumors with thromboembolic events: LMWH at therapeutic dose for 6 months (first month at full dose, 5 months at 75% dose) is superior to warfarin 2

Anticoagulation to AVOID

• Never use heparin in hyperfibrinolytic DIC 2
• Warfarin is ineffective in chronic DIC 6

Step 5: Monitoring

Monitor complete blood count and coagulation screen (including fibrinogen and D-dimer) regularly 1, 2:

• Acute severe DIC: Daily monitoring 1
• Chronic stable DIC: Monthly monitoring 1
• Diagnostic pearl: A 30% or greater drop in platelet count is diagnostic of subclinical DIC, even when absolute values remain normal 1, 2
• Additional monitoring: Periodically check hematocrit and occult blood in stool 5

Special Clinical Scenarios

ICU Patients with Sepsis

• Use two-step sequential screening: First apply ISTH Sepsis-Induced Coagulopathy (SIC) score (≥4 points indicates SIC), then ISTH overt DIC score (≥5 points indicates overt DIC) for patients with more advanced coagulopathy 1
• Sequential screening on ICU admission and 2 days later is associated with lower mortality 1
• Anticoagulant therapy may improve outcomes specifically in septic patients with coagulopathy or DIC, though evidence remains controversial 1

Acute-on-Chronic Liver Failure

• Treatment of the underlying cause of ACLF is fundamental 7
• Early identification and management of precipitating factors (bacterial infections, GI bleeding, drug toxicity) is crucial 7
• Admit to intensive care or intermediate care units with early transplant center referral if appropriate 7
• Avoid prophylactic transfusions based solely on laboratory values 7

Cancer-Associated DIC Requiring Long-Term Management

• If DIC persists because tumor does not regress, long-term outpatient subcutaneous heparin therapy may be required 6

Agents NOT Recommended

• Antithrombin concentrate: Cannot be recommended in absence of prospective evidence from randomized controlled trials confirming benefit on clinically relevant endpoints in patients with DIC not receiving heparin 4
• Antifibrinolytic agents: Should NOT be used in general DIC management; only consider lysine analogues (tranexamic acid 1 g every 8 hours) in DIC characterized by primary hyperfibrinolytic state with severe bleeding 4
• Recombinant human activated protein C: May be considered in severe sepsis with DIC, but avoid in patients at high risk of bleeding or platelet counts <30×10⁹/L 4
• Extracorporeal liver support systems: Have not shown significant survival benefit in ACLF and are not recommended 7

Critical Pitfalls to Avoid

• Do not delay treatment of underlying condition: All supportive measures are futile without addressing the root cause 1, 2
• Do not transfuse based on laboratory values alone: Reserve transfusions for bleeding patients or those requiring invasive procedures 4
• Do not withhold anticoagulation due to abnormal coagulation tests alone: In absence of active bleeding, coagulation abnormalities should not prevent prophylactic anticoagulation 2
• Do not use heparin in hyperfibrinolytic DIC: This subtype requires different management focused on replacing coagulation factors and potentially using antifibrinolytics 2, 4