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

Treatment for Disseminated Intravascular Coagulation (DIC)

Treat the underlying disease immediately as the cornerstone of DIC management, while simultaneously providing supportive hemostatic therapy with blood products based on specific thresholds and initiating prophylactic anticoagulation in most cases. 1, 2

Core Treatment Algorithm

1. Address the Underlying Cause (First Priority)

The fundamental treatment is eliminating the trigger for DIC, as this is FDA-approved and guideline-mandated 3:

• In cancer-associated DIC: Initiate chemotherapy, surgery, or radiation immediately 1, 2
• In acute promyelocytic leukemia: Start all-trans retinoic acid urgently, which achieves excellent DIC resolution 1, 2
• In sepsis-associated DIC: Implement source control and appropriate antibiotics 2
• In obstetrical complications: Deliver the fetus/placenta and manage the specific complication 4

2. Supportive Hemostatic Management

The International Society on Thrombosis and Haemostasis (ISTH) provides specific transfusion thresholds 1, 2:

Platelet Transfusion

• Active bleeding: Maintain platelets >50×10⁹/L 1, 2, 5
• High bleeding risk without active bleeding (surgery, invasive procedures):
  • Transfuse if <30×10⁹/L in acute promyelocytic leukemia 1
  • Transfuse if <20×10⁹/L in other cancers 1
• No bleeding and low bleeding risk: Transfuse if <20-30×10⁹/L 6

Critical caveat: Transfused platelet lifespan is extremely short in DIC due to ongoing consumption, requiring frequent monitoring 1, 7

Fresh Frozen Plasma (FFP)

• Active bleeding with prolonged coagulation times: Administer 15-30 mL/kg 1, 2, 5
• Monitor carefully for volume overload 1
• Alternative if volume overload is a concern: Use prothrombin complex concentrates 1

Fibrinogen Replacement

• If fibrinogen remains <1.5 g/L despite FFP in actively bleeding patients: Transfuse 2 pools of cryoprecipitate or fibrinogen concentrate 1, 2, 5

3. Anticoagulation Strategy

The ISTH recommends anticoagulation in most DIC cases, with critical exceptions 1, 2:

When to Anticoagulate

• Prophylactic anticoagulation is recommended in all cancer-related DIC patients EXCEPT those with hyperfibrinolytic DIC 1, 2
• Use low molecular weight heparin (LMWH) as first choice 2, 7
• Heparin is FDA-approved for "acute and chronic consumptive coagulopathies (disseminated intravascular coagulation)" 3

Contraindications to Anticoagulation

• Platelet count <20×10⁹/L 1, 7
• Active bleeding 1, 7
• Hyperfibrinolytic DIC (typical of acute promyelocytic leukemia and metastatic prostate cancer) 1, 2

Dosing

• Prophylactic dose: Standard LMWH prophylactic dosing 1, 6
• Therapeutic dose: If arterial or venous thrombosis develops, escalate to therapeutic anticoagulation 1, 2
• Unfractionated heparin alternative: Consider in renal failure due to reversibility 7

Important distinction: Coagulation abnormalities alone should NOT be considered an absolute contraindication to anticoagulation in the absence of active bleeding 7

4. Monitoring Requirements

The ISTH recommends regular surveillance 1, 2:

• Laboratory monitoring: Complete blood count, PT/aPTT, fibrinogen, and D-dimer 1, 2
• Frequency: Daily in acute severe DIC to monthly in chronic stable DIC 2
• Diagnostic threshold for subclinical DIC: ≥30% drop in platelet count, even if absolute values remain normal 1, 2
• Monitor for complications: Organ failure, bleeding, thrombosis 1

DIC Subtype-Specific Management

The ISTH classifies DIC into three forms requiring different approaches 2:

Procoagulant DIC (Thrombosis Predominates)

• Common in pancreatic cancer and adenocarcinomas 2
• Management: Emphasize prophylactic or therapeutic anticoagulation 1, 2

Hyperfibrinolytic DIC (Bleeding Predominates)

• Typical of acute promyelocytic leukemia and metastatic prostate cancer 2
• Management: AVOID routine anticoagulation 1, 2
• Antifibrinolytics: NOT recommended routinely; may consider tranexamic acid only if therapy-resistant bleeding dominates 1, 5

Subclinical DIC

• Diagnosed by ≥30% platelet drop without clinical manifestations 1, 2
• Management: Treat underlying disease and monitor closely 1

Treatments NOT Recommended

The ISTH explicitly advises against 1, 5:

• Routine tranexamic acid: May increase thrombotic events; only consider in therapy-resistant hyperfibrinolytic bleeding 1, 5
• Recombinant Factor VIIa: No controlled trial evidence and significant thrombotic risk 1, 5
• Prophylactic transfusions based solely on laboratory values: Without active bleeding or high bleeding risk 5

Critical Pitfalls to Avoid

• Medication errors: Confirm correct heparin vial strength before administration, as fatal errors have occurred 3
• Delayed underlying disease treatment: DIC will not resolve without addressing the root cause 1, 2
• Ignoring platelet trends: A 30% drop is diagnostic even with normal absolute counts 1, 2
• Anticoagulating hyperfibrinolytic DIC: This can worsen bleeding 1, 2
• Expecting long-lasting transfusion effects: Product half-life is very short in active DIC 1, 7