What is the primary approach to managing Disseminated Intravascular Coagulation (DIC)?

Management of Disseminated Intravascular Coagulation (DIC)

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

Primary Treatment Algorithm

Step 1: Address the Root Cause (Non-Negotiable First Priority)

The International Society on Thrombosis and Haemostasis (ISTH) establishes that treating the underlying disease process is the foundation of all DIC therapy. 1 Without controlling the trigger, supportive measures alone will fail. 2

Disease-specific interventions:

• Sepsis-associated DIC: Initiate source control and appropriate antibiotics immediately 1
• Cancer-associated DIC: Begin chemotherapy, surgery, or radiation as indicated 1
• Acute promyelocytic leukemia: Start all-trans retinoic acid early for good DIC resolution 1
• Obstetrical complications: Deliver the fetus/placenta or address retained products 3

Step 2: Classify the DIC Subtype (Determines Management Strategy)

The ISTH recognizes three distinct forms requiring different approaches: 1

Procoagulant DIC (thrombosis predominates):

• Common in pancreatic cancer and adenocarcinomas 1
• Presents with arterial ischemia, venous thromboembolism, or microvascular thrombosis 1
• Management: Initiate prophylactic anticoagulation with low molecular weight heparin (LMWH) as first choice 1
• Escalate to therapeutic-dose anticoagulation if arterial or venous thrombosis develops 1

Hyperfibrinolytic DIC (bleeding predominates):

• Typical of acute promyelocytic leukemia and metastatic prostate cancer 1
• Presents with widespread bleeding from multiple sites 1
• Management: DO NOT use heparin in this subtype 1
• Focus on aggressive component replacement and treating underlying malignancy 1

Subclinical DIC:

• Diagnosed by ≥30% drop in platelet count even when absolute values remain normal 1
• Management: Prophylactic anticoagulation unless contraindicated 1

Step 3: Supportive Hemostatic Measures (Only After Step 1 is Initiated)

Platelet transfusion thresholds:

• Active bleeding: Maintain platelets >50×10⁹/L 1, 2
• High bleeding risk without active hemorrhage: Transfuse if <30×10⁹/L in acute promyelocytic leukemia or <20×10⁹/L in other cancers 1
• Non-bleeding patients: Prophylactic transfusion not recommended unless high bleeding risk perceived 2

Plasma and fibrinogen replacement:

• Active bleeding with prolonged PT/aPTT: Administer 15-30 mL/kg fresh frozen plasma (FFP) 1, 2
• Persistent fibrinogen <1.5 g/L despite FFP: Give cryoprecipitate or fibrinogen concentrate 1, 2
• Do not transfuse based on laboratory values alone—reserve for bleeding patients or those requiring invasive procedures 2

Critical caveat: Transfused products have very short half-life in DIC with vigorous coagulation activation, so repeated dosing may be necessary. 1

Step 4: Anticoagulation Strategy (Except Hyperfibrinolytic DIC)

The ISTH recommends initiating prophylactic anticoagulation with heparin in all patients EXCEPT those with hyperfibrinolytic DIC, unless contraindications exist. 1

Specific anticoagulation guidance:

• First-line choice: Low molecular weight heparin (LMWH) for most patients 1
• Therapeutic-dose anticoagulation indications: Arterial/venous thrombosis, severe purpura fulminans with acral ischemia, vascular skin infarction 1, 2
• High bleeding risk with renal failure: Use unfractionated heparin (UFH) for reversibility 1
• Contraindications: Platelets <20×10⁹/L or active bleeding in solid tumor DIC 1

Important principle: Abnormal coagulation tests alone should NOT be considered an absolute contraindication to anticoagulation in the absence of active bleeding. 1

Step 5: Monitoring Protocol

Laboratory monitoring frequency: 1

• Acute severe DIC: Daily complete blood count and coagulation screen (PT, aPTT, fibrinogen, D-dimer)
• Chronic stable DIC: Monthly monitoring
• Intermediate cases: Adjust frequency based on clinical stability

Key monitoring threshold: A 30% or greater drop in platelet count is diagnostic of subclinical DIC progression, even when absolute platelet values remain normal. 1

Common Pitfalls to Avoid

1. Never delay treating the underlying disease while focusing on laboratory abnormalities—DIC becomes irreversible once established and carries considerable mortality. 4

2. Do not use heparin in hyperfibrinolytic DIC—this will worsen bleeding. 1

3. Do not transfuse components based solely on laboratory values—clinical bleeding or high bleeding risk must be present. 2

4. Do not use antifibrinolytic agents (tranexamic acid) in general DIC—reserve only for primary hyperfibrinolytic states with severe bleeding. 2

5. Recognize that advanced overt DIC may have progressed beyond the point where anticoagulant therapy provides benefit—earlier intervention is critical. 1

Special Considerations

ICU patients with sepsis: Use the ISTH two-step sequential screening (SIC score ≥4, then overt DIC score ≥5) on admission and 2 days later, as this approach is associated with lower mortality. 1

Proximal lower limb thrombosis with anticoagulation contraindication: Consider temporary IVC filter placement. 1

Solid tumors with thromboembolic events: LMWH at therapeutic dose for 6 months (full dose first month, then 75% dose for 5 months) is superior to warfarin. 1