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 hemostatic care with blood products based on specific thresholds and initiating prophylactic anticoagulation in most cases except hyperfibrinolytic DIC. 1, 2

Core Treatment Algorithm

1. Address the Underlying Cause (Priority #1)

• Initiate definitive treatment of the underlying condition immediately, as DIC resolution depends entirely on controlling the trigger mechanism 1, 2, 3
• For acute promyelocytic leukemia: start all-trans retinoic acid urgently, which achieves excellent DIC resolution 1, 2
• For sepsis-associated DIC: implement source control and appropriate antibiotics immediately 2
• For cancer-associated DIC: initiate chemotherapy, surgery, or radiation as indicated without delay 1, 2
• For obstetrical complications: deliver the fetus/placenta or address the specific obstetrical emergency 4

2. Classify the DIC Subtype (Determines Anticoagulation Strategy)

DIC presents in three distinct forms requiring different management approaches 1, 2:

• Procoagulant DIC (common in pancreatic cancer, adenocarcinomas): presents with arterial ischemia, venous thromboembolism, or microvascular thrombosis—requires anticoagulation 1, 2
• Hyperfibrinolytic DIC (typical of acute promyelocytic leukemia, metastatic prostate cancer): presents with widespread bleeding from multiple sites—avoid anticoagulation 1, 2
• Subclinical DIC: only laboratory abnormalities without overt bleeding or thrombosis—requires prophylactic anticoagulation 1, 2

3. Supportive Hemostatic Management

Platelet Transfusion Thresholds

• Active bleeding: transfuse platelets to maintain count >50×10⁹/L 1, 2, 3
• High bleeding risk without active bleeding (surgery, invasive procedures): transfuse if platelets <30×10⁹/L in acute promyelocytic leukemia or <20×10⁹/L in other cancers 1
• Critical caveat: transfused platelet lifespan is very short in DIC with vigorous coagulation activation, requiring frequent re-dosing 1

Fresh Frozen Plasma (FFP)

• Active bleeding with prolonged PT/aPTT: administer 15-30 mL/kg of FFP with careful clinical monitoring 1, 2, 3
• Volume overload concerns: use prothrombin complex concentrates instead, though these only partially correct the defect as they lack all coagulation factors 1, 3
• Do not transfuse FFP based solely on laboratory values in non-bleeding patients 3

Fibrinogen Replacement

• Persistent hypofibrinogenemia <1.5 g/L despite FFP in actively bleeding patients: transfuse two pools of cryoprecipitate (where available) or fibrinogen concentrate 1, 2, 3

4. Anticoagulation Strategy

When to Anticoagulate

Initiate prophylactic anticoagulation with heparin in all DIC patients EXCEPT those with hyperfibrinolytic DIC, unless contraindications exist 1, 2, 5:

• Contraindications: platelet count <20×10⁹/L or active bleeding 1
• Preferred agent: low molecular weight heparin (LMWH) as first choice for most patients 1, 2
• Alternative: unfractionated heparin in patients with renal failure (due to reversibility) or high bleeding risk (due to short half-life) 1, 3

Escalate to Therapeutic Anticoagulation

Use therapeutic-dose anticoagulation in procoagulant DIC with 1, 2, 3:

• Arterial or venous thromboembolism
• Severe purpura fulminans with acral ischemia
• Vascular skin infarction

Dosing for therapeutic anticoagulation: weight-adjusted doses (e.g., 10 units/kg/h unfractionated heparin) may be used without necessarily prolonging aPTT to 1.5-2.5 times control, as monitoring aPTT in DIC is complicated 3

Critical Anticoagulation Pitfall

Never use anticoagulation in hyperfibrinolytic DIC (acute promyelocytic leukemia, metastatic prostate cancer with bleeding phenotype), as this will worsen hemorrhage 1

5. Monitoring Requirements

• Regular monitoring: complete blood count and coagulation screen (PT, aPTT, fibrinogen, D-dimer) 1, 2
• Frequency: ranges from daily in acute severe DIC to monthly in chronic stable DIC, decided case-by-case 1, 2
• Subclinical DIC diagnosis: a ≥30% drop in platelet count is diagnostic even when absolute values remain normal 1, 2
• Monitor for occult blood in stool and hematocrit throughout treatment 5

6. Agents to Avoid

• Antifibrinolytic agents (tranexamic acid): not recommended in DIC and may increase thrombotic events; only consider in rare hyperfibrinolytic DIC with severe bleeding 6, 3
• Recombinant Factor VIIa: not recommended due to thrombotic risks and lack of controlled trial evidence 6
• Direct oral anticoagulants (DOACs): limited evidence suggests low prophylaxis efficacy; may be considered in chronic thrombotic DIC but avoid in bleeding phenotypes 7

7. Special Considerations

Cancer-Associated DIC with Thrombosis

• For solid tumors with thromboembolic events: use LMWH at therapeutic dose for 6 months (first month at full dose, subsequent 5 months at 75% dose), which is superior to warfarin 8

Sepsis-Associated DIC

• Consider recombinant human activated protein C (24 mcg/kg/h continuous infusion for 4 days) in severe sepsis with DIC, though contraindicated if platelets <30×10⁹/L 3
• Note: This agent increases bleeding risk and has limited current availability 9

Renal or Hepatic Impairment

• Organ failure decreases platelet and fibrinogen production, requiring more frequent monitoring and adjusted replacement thresholds 1

Common Pitfalls to Avoid

• Do not delay treatment of underlying disease while waiting for laboratory confirmation—prompt recognition and immediate action on the trigger is essential 1, 2, 3
• Do not withhold anticoagulation based solely on abnormal coagulation tests in the absence of active bleeding, as laboratory abnormalities alone are not absolute contraindications 8
• Do not use prophylactic transfusions based only on laboratory values without clinical bleeding or high bleeding risk 3
• Do not assume normal platelet counts exclude DIC—a profound decrease from very high baseline levels may still indicate active DIC 1