How to treat Disseminated Intravascular Coagulation (DIC)?

Treatment of Disseminated Intravascular Coagulation (DIC)

Treat the underlying disease process immediately—this is the absolute cornerstone of DIC management and takes priority over all supportive measures. 1

Step 1: Identify and Treat the Underlying Cause

The first and most critical intervention is addressing the root cause of DIC:

• In sepsis-associated DIC: Initiate source control and appropriate antibiotics immediately 1
• In cancer-associated DIC: Start appropriate cancer therapy (chemotherapy, surgery, or radiation) without delay 1
• In acute promyelocytic leukemia: Begin all-trans retinoic acid early, which achieves good resolution of DIC 1
• In obstetrical complications, trauma, or other triggers: Address the specific underlying condition aggressively 2

Step 2: Classify the DIC Subtype

DIC presents in three distinct forms that require different management approaches 1:

Procoagulant DIC (Thrombosis Predominates)

• Common in: Pancreatic cancer, adenocarcinomas, hepatocellular carcinoma 1, 3
• Presents with: Arterial ischemia, venous thromboembolism, microvascular thrombosis 1
• Treatment approach: Underlying cancer therapy PLUS prophylactic anticoagulation with heparin or LMWH 3

Hyperfibrinolytic DIC (Bleeding Predominates)

• Common in: Acute promyelocytic leukemia, metastatic prostate cancer 1
• Presents with: Widespread bleeding from multiple sites 1
• Treatment approach: Underlying cancer therapy PLUS supportive care with blood products; do NOT use routine anticoagulation 3

Subclinical DIC

• Characterized by: Laboratory abnormalities without obvious clinical symptoms; ≥30% drop in platelet count is diagnostic even when absolute values remain normal 1, 3
• Treatment approach: Underlying cancer therapy PLUS prophylactic anticoagulation 3

Step 3: Anticoagulation Strategy

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

Prophylactic Dosing

• First choice: Low molecular weight heparin (LMWH) for most patients 1
• Alternative: Unfractionated heparin at prophylactic doses 1
• Continue until: Bleeding ensues or platelet count drops below 30×10⁹/L 4
• FDA-approved indication: Heparin is specifically indicated for treatment of acute and chronic consumptive coagulopathies (DIC) 5

Therapeutic Dosing

• Escalate to therapeutic-dose anticoagulation if: Arterial or venous thrombosis develops, severe purpura fulminans with acral ischemia, or vascular skin infarction occurs 1, 6
• Dosing for therapeutic effect: Initial 5,000 units IV bolus followed by continuous infusion of 20,000-40,000 units/24 hours, or intermittent IV dosing of 10,000 units initially then 5,000-10,000 units every 4-6 hours 5
• Consider continuous infusion UFH in patients with high bleeding risk due to its short half-life and reversibility; weight-adjusted doses (10 units/kg/h) may be used without necessarily prolonging aPTT to 1.5-2.5 times control 6

Special Scenarios

• Temporary IVC filter: Consider only if proximal lower limb thrombosis exists with absolute contraindication to anticoagulation 1, 3

Step 4: Blood Product Support

Do NOT transfuse based on laboratory values alone—reserve transfusions for patients with active bleeding or high bleeding risk (e.g., pre-procedure). 6, 4

Platelet Transfusion

• Target for active bleeding: Maintain platelet count >50×10⁹/L 1, 6, 4
• Target for non-bleeding patients: Consider transfusion at 20-30×10⁹/L only if high bleeding risk exists 6, 4
• Do NOT give prophylactic platelet transfusion in non-bleeding patients without high bleeding risk 6

Fresh Frozen Plasma (FFP)

• Indication: Prolonged PT/aPTT with active bleeding or pre-procedure 1, 6
• Dosing: 15-30 mL/kg 1
• Important: There is no evidence that FFP infusion stimulates ongoing coagulation activation 6

Fibrinogen Replacement

• Indication: Fibrinogen <1.5 g/L despite FFP administration 1
• Options: Cryoprecipitate or fibrinogen concentrate 1, 6

Prothrombin Complex Concentrate

• Consider if: FFP transfusion not possible due to fluid overload in bleeding patients 6
• Limitation: Only partially corrects defect as it contains selected factors, not the global deficiency present in DIC 6

Step 5: Monitoring Strategy

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

• Acute severe DIC: Daily monitoring 1
• Chronic stable DIC: Monthly monitoring 1
• ICU patients: Use ISTH SIC score (≥4 points) on admission and 2 days later; sequential screening is associated with lower mortality 1
• Monitor for: Platelet count trends (≥30% drop is diagnostic of subclinical DIC), hematocrit, and occult blood in stool 1, 5

Critical Agents to AVOID

Tranexamic Acid

Routine use of tranexamic acid in DIC is strongly discouraged due to increased thrombotic risks. 3, 7

• Do NOT use in: Non-hyperfibrinolytic forms of DIC as it may worsen outcomes 7
• Only consider in: Hyperfibrinolytic DIC with therapy-resistant bleeding that dominates the clinical picture 7, 6
• Confirm hyperfibrinolysis first: Use APTEM testing (thromboelastometric monitoring) before administering 7
• Dosing if used: 10-15 mg/kg loading dose followed by 1-5 mg/kg/hour infusion 7

Recombinant Factor VIIa

Do NOT use routinely in cancer-associated DIC due to increased thrombotic risks and lack of controlled trial evidence 3

Common Pitfalls to Avoid

• Do not delay treatment of the underlying condition while focusing solely on coagulation abnormalities—this is the most common error 1, 2
• Do not anticoagulate hyperfibrinolytic DIC unless thrombosis develops—focus on blood product support instead 3
• Do not transfuse based on laboratory values alone in non-bleeding patients without high bleeding risk 6, 4
• Do not use antifibrinolytics routinely—they increase thrombotic risk in most DIC subtypes 3, 7, 6
• Do not assume all DIC is the same—classification into subtypes is essential for appropriate management 1, 3