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

Management of Disseminated Intravascular Coagulation

The cornerstone of DIC management is aggressive treatment of the underlying disorder, followed by subtype-specific supportive care: anticoagulation with heparin for procoagulant/subclinical DIC, blood product support for hyperfibrinolytic DIC, and avoidance of routine antifibrinolytics due to thrombotic risk. 1, 2, 3

Initial Classification and Risk Stratification

Categorize DIC into one of three subtypes to guide management:

• Procoagulant DIC presents with thrombotic complications (arterial ischemia, venous thromboembolism, digital ischemia, cerebrovascular events, peripheral neuropathy, ischemic colitis) and is most common in pancreatic cancer and adenocarcinomas 1, 2, 4

• Hyperfibrinolytic DIC presents with bleeding complications (widespread bruising, mucosal bleeding, CNS hemorrhage, pulmonary/GI bleeding) and is characteristic of acute promyelocytic leukemia and metastatic prostate cancer 1, 2, 4

• Subclinical DIC shows only laboratory abnormalities (thrombocytopenia, hypofibrinogenemia, microangiopathic hemolytic anemia, elevated D-dimer) without obvious clinical symptoms 1, 2, 4

• Assess both thrombotic and bleeding risk in all cancer-associated DIC patients before initiating treatment 1, 4

Laboratory Diagnosis and Monitoring

Key diagnostic markers include:

• Decreasing platelet count (≥30% drop is diagnostic even without clinical manifestations) 2, 4
• Elevated D-dimer levels 4, 5
• Prolonged PT/aPTT 6, 5
• Decreased fibrinogen (though may be normal initially) 4, 5

Monitoring frequency:

• Range from monthly in stable subclinical DIC to daily in acute bleeding/thrombotic presentations 2
• Regular blood counts, clotting screens, fibrinogen, and D-dimer are essential 2
• Repeat testing is critical as DIC is a dynamically changing scenario 6

Treatment Algorithm by DIC Subtype

Procoagulant DIC (Thrombosis-Predominant)

• Treat underlying malignancy or trigger aggressively 1, 2, 4

• Prophylactic-dose heparin or LMWH in all patients without contraindications 2, 3

  • Heparin is FDA-approved for treatment of acute and chronic consumptive coagulopathies including DIC 3
  • Initial dose: 5,000 units IV bolus followed by continuous infusion of 20,000-40,000 units/24 hours 3
  • Weight-adjusted dosing (e.g., 10 units/kg/hour) may be used without necessarily prolonging aPTT to 1.5-2.5 times control 6

• Therapeutic-dose anticoagulation if arterial or venous thrombosis develops 2

• For severe purpura fulminans with acral ischemia or vascular skin infarction, therapeutic doses of heparin are indicated 6, 7

Hyperfibrinolytic DIC (Bleeding-Predominant)

• Treat underlying malignancy or trigger aggressively 1, 2, 4

• Supportive care with blood products 1, 2

  • Platelet transfusion to maintain count >50 × 10⁹/L in actively bleeding patients 2, 6
  • Fresh frozen plasma (FFP) for prolonged PT/PTT with active bleeding, not based on laboratory values alone 2, 6
  • Fibrinogen concentrate or cryoprecipitate if severe hypofibrinogenemia (<1 g/L) persists despite FFP 6

• Do NOT routinely anticoagulate hyperfibrinolytic DIC 2

• Avoid tranexamic acid and recombinant FVIIa routinely due to increased thrombotic risks and lack of controlled trial evidence 2

  • Exception: Lysine analogues like tranexamic acid (1 g every 8 hours) may be considered only in primary hyperfibrinolytic DIC with severe bleeding 6

Subclinical DIC

• Treat underlying malignancy 1, 2, 4

• Prophylactic-dose heparin or LMWH 1, 2

• Monitor closely for progression to overt DIC 2, 4

Special Clinical Scenarios

New Thrombosis with Severe Thrombocytopenia

Three possible approaches 2:

• Platelet transfusions plus therapeutic anticoagulation
• Intermediate or prophylactic-dose anticoagulation without transfusions
• No anticoagulation unless thrombus is in a critical location (e.g., cerebral, mesenteric)

Proximal Lower Limb Thrombosis with Absolute Contraindication to Anticoagulation

• Consider temporary IVC filter placement only in this specific scenario 2

Critically Ill Non-Bleeding Patients

• Prophylactic doses of heparin or LMWH for venous thromboembolism prevention 6

Patients Requiring Invasive Procedures

• Platelet transfusion if count <50 × 10⁹/L 6
• FFP administration for prolonged PT/aPTT with planned procedure 6

Agents to AVOID

• Antithrombin III concentrate: No prospective evidence of benefit on clinically relevant endpoints in DIC patients not receiving heparin 6

• Recombinant activated protein C: While considered in severe sepsis with DIC, contraindicated if platelet count <30 × 10⁹/L and in patients at high bleeding risk 6

• Routine antifibrinolytics: Should not be used in general DIC management due to thrombotic risk 2, 6

Critical Pitfalls to Avoid

• Do not transfuse blood products based solely on laboratory values—reserve for active bleeding or high bleeding risk situations 6

• Do not confuse heparin vial strengths—fatal hemorrhages have occurred in pediatric patients when 10,000 units/mL vials were confused with catheter lock flush vials 3

• Do not delay treatment of the underlying disorder—this is the absolute cornerstone of DIC management and supersedes all supportive measures 1, 6, 5

• Do not use heparin in patients with history of heparin-induced thrombocytopenia (HIT/HITTS)—this is an absolute contraindication 3

• Do not assume normal platelet count excludes DIC—a profound decrease from a very high baseline may be the only sign in some malignancy patients 4

Ongoing Surveillance

• Regular clinical and laboratory surveillance is mandatory to assess response and detect complications 2

• Tailor interventions to available resources and patient preferences regarding goals of care, especially in metastatic disease with poor prognosis 2

• Monitor for signs of HIT/HITTS in all patients receiving heparin and discontinue immediately if suspected 3