What is the management of Disseminated Intravascular Coagulation (DIC)?

Management of Disseminated Intravascular Coagulation (DIC)

The fundamental management of DIC is aggressive treatment of the underlying disorder, combined with supportive transfusion therapy guided by specific thresholds and selective anticoagulation with heparin in thrombotic-predominant cases. 1, 2

Core Management Principles

Treat the Underlying Cause First

• Identifying and treating the precipitating condition is the cornerstone of DIC management and takes absolute priority over all other interventions. 1, 2
• In acute promyelocytic leukemia (APL), early initiation of all-trans retinoic acid (ATRA) induction therapy achieves excellent DIC resolution. 1, 3
• In sepsis-associated DIC, source control and appropriate antibiotics are critical. 4
• In cancer-associated DIC, treatment of the underlying malignancy is essential. 1

Regular Laboratory Monitoring

• Monitor complete blood count, PT/aPTT, fibrinogen, and D-dimer regularly—frequency ranges from daily in acute DIC to monthly in chronic cases depending on clinical severity. 1, 2, 5
• A 30% or greater drop in platelet count should be considered diagnostic of subclinical DIC even without clinical bleeding. 1, 2, 5
• Be aware that PT/aPTT may be normal in early or cancer-associated DIC, particularly when coagulation factors are only moderately decreased. 1, 5
• A normal platelet count does not exclude DIC in patients with baseline thrombocytosis from malignancy—look for decreasing trends. 1, 5

Supportive Transfusion Therapy

Platelet Transfusion Thresholds

• In patients with DIC and active bleeding: maintain platelet count >50×10⁹/L. 1, 2, 5, 6
• In patients at high risk of bleeding without active hemorrhage (e.g., surgery, invasive procedures): transfuse if platelets <30×10⁹/L in APL or <20×10⁹/L in other cancers. 1, 2, 6
• Do not transfuse prophylactically based solely on laboratory values in the absence of bleeding or high-risk procedures. 4, 5
• Recognize that transfused platelets may have very short lifespan in DIC with vigorous coagulation activation. 1, 2

Fresh Frozen Plasma (FFP)

• In patients with DIC and active bleeding: administer 15-30 mL/kg of FFP with careful clinical monitoring. 1, 2, 5
• If volume overload is a concern, consider prothrombin complex concentrates instead. 1

Fibrinogen Replacement

• In actively bleeding patients with persistently low fibrinogen (<1.5 g/L) despite FFP: transfuse two pools of cryoprecipitate or fibrinogen concentrate. 1, 2, 5
• Fibrinogen is typically consumed and low in DIC (unlike TTP where it remains normal). 5

Anticoagulation Strategy

When to Use Heparin

• Heparin is indicated primarily in thrombotic-predominant forms of DIC, particularly in cancer-associated DIC with solid tumors. 1, 5, 7
• In cancer-associated DIC without bleeding: consider prophylactic heparin (unfractionated or low-molecular-weight) in the absence of contraindications. 1, 2
• Heparin is specifically indicated in purpura fulminans, venous thromboembolism, and acute promyelocytic leukemia. 8

Contraindications to Heparin

• Do not use heparin if platelets <20×10⁹/L or if active bleeding is present. 1, 2, 5
• Avoid heparin in DIC with predominant hyperfibrinolysis. 2

Choice of Heparin Formulation

• In patients with high bleeding risk and renal failure: prefer unfractionated heparin (UFH) due to reversibility. 2
• In other cases: prefer low-molecular-weight heparin (LMWH). 2
• For cancer-associated thromboembolism: LMWH at therapeutic dose for 6 months (first month at full dose, subsequent 5 months at 75% dose) is superior to warfarin. 2

Critical Pitfalls to Avoid

• Abnormal coagulation tests alone should not be considered an absolute contraindication to anticoagulation in the absence of active bleeding. 2
• Do not rely solely on PT/aPTT for diagnosis—these may be normal in approximately 50% of DIC cases, especially early or cancer-associated forms. 1, 5
• In patients with baseline thrombocytosis from malignancy, a "normal" platelet count may actually represent a significant drop and be the only sign of DIC. 1
• The lifespan of all transfused blood products may be extremely short in DIC with vigorous coagulation activation and fibrinolysis, requiring frequent reassessment. 1, 2

Special Populations

Cancer-Associated DIC

• Risk-assess all cancer patients with DIC for likelihood of both thrombosis and bleeding. 1
• In metastatic disease with poor prognosis, tailor interventions based on physician discretion, patient preferences, and available resources. 1

Acute-on-Chronic Liver Failure

• Standard coagulation tests like INR correlate poorly with bleeding risk in cirrhotic patients. 4
• Early identification of precipitating factors (infections, GI bleeding, drug toxicity) is crucial for survival. 4
• Admit to intensive care or intermediate care units with early transplant center referral when appropriate. 4