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

Treatment of Disseminated Intravascular Coagulation (DIC)

The cornerstone of DIC treatment is addressing the underlying disease process, supplemented by blood product transfusions based on specific thresholds and selective use of heparin anticoagulation in thrombotic-predominant cases. 1, 2

Immediate Priorities

Treat the Underlying Cause

• This is the single most critical intervention - DIC will not resolve without controlling the precipitating condition (sepsis, malignancy, trauma, obstetric complications) 1, 2, 3
• In acute promyelocytic leukemia, early initiation of induction therapy achieves excellent DIC resolution 1, 2
• In sepsis, source control and antimicrobial therapy are paramount 3, 4

Monitor Closely

• Obtain baseline complete blood count, PT/aPTT, fibrinogen, and D-dimer 1, 2, 3
• Repeat these tests frequently (daily in acute DIC) to track progression 1, 2, 3
• A platelet count drop ≥30% from baseline indicates subclinical DIC progression even without overt bleeding 1, 2, 3

Blood Product Replacement

Platelet Transfusion Thresholds

• Active bleeding: Maintain platelets >50×10⁹/L 1, 2, 3, 4
• High bleeding risk without active hemorrhage:
  • Acute promyelocytic leukemia: Transfuse if <30×10⁹/L 1, 2
  • Other cancers or conditions: Transfuse if <20×10⁹/L 1, 2
• Do not transfuse prophylactically based solely on laboratory values in non-bleeding patients without high-risk procedures 3, 4
• Note that transfused platelets have a very short lifespan in DIC due to ongoing consumption 1, 2

Fresh Frozen Plasma (FFP)

• Active bleeding with prolonged PT/aPTT: Administer 15-30 mL/kg 1, 2, 3, 4
• Adjust dosing based on clinical response and repeat coagulation studies 1
• If volume overload is a concern, consider prothrombin complex concentrates instead, though these only partially correct the defect as they lack all coagulation factors 1, 4
• Do not give FFP based on laboratory abnormalities alone in non-bleeding patients 4, 5

Fibrinogen Replacement

• If fibrinogen remains <1.5 g/L despite FFP administration in actively bleeding patients, give cryoprecipitate (two pools) or fibrinogen concentrate 1, 2, 3, 4
• Fibrinogen depletes first in DIC and requires specific replacement 6

Anticoagulation with Heparin

When to Use Heparin

Heparin is FDA-approved for DIC treatment 7 and should be considered in specific scenarios:

• Thrombotic-predominant DIC: Arterial/venous thromboembolism, severe purpura fulminans with acral ischemia, or vascular skin infarction 1, 4
• Cancer-associated DIC (solid tumors): Prophylactic-dose heparin in absence of contraindications 1, 2
• Subclinical DIC: Prophylactic anticoagulation is beneficial 1
• Critically ill non-bleeding patients: VTE prophylaxis with prophylactic-dose heparin or LMWH 4

Contraindications to Heparin

• Active bleeding 1, 7
• Platelet count <20×10⁹/L 1, 2
• Hyperfibrinolytic DIC (avoid heparin in this subtype) 1, 2

Choice of Heparin Formulation

• Unfractionated heparin (UFH): Preferred in high bleeding risk and renal failure due to easier reversibility and short half-life 1, 2, 4
• Low-molecular-weight heparin (LMWH): Preferred in all other cases 1, 2
• For therapeutic anticoagulation in thrombotic DIC, use weight-adjusted UFH (e.g., 10 units/kg/hour) without necessarily targeting aPTT prolongation of 1.5-2.5× control 4

Special Consideration for Thromboembolic Events

• In solid tumor patients with new thromboembolism: LMWH at therapeutic dose for 6 months (full dose for 1 month, then 75% dose for 5 months) is superior to warfarin 1, 2

Agents to Avoid

Antifibrinolytic Agents

• Do not routinely use tranexamic acid or epsilon aminocaproic acid 1, 4
• These agents showed no clear benefit in reducing hemorrhagic deaths in acute promyelocytic leukemia and may increase thrombotic events 1
• Consider only in therapy-resistant bleeding with documented hyperfibrinolytic DIC 1, 4

Critical Pitfalls to Avoid

• Do not confuse heparin vial strengths - fatal medication errors have occurred, particularly in pediatrics, when concentrated 10,000 units/mL vials were mistaken for catheter lock flush products 7
• Do not withhold anticoagulation solely based on abnormal PT/aPTT - in the absence of active bleeding, these abnormalities reflect a rebalanced hemostasis and are not absolute contraindications 1
• Do not rely on PT/aPTT alone for diagnosis - these may be normal in early or cancer-associated DIC 3
• Do not ignore decreasing platelet trends in patients with baseline thrombocytosis - a 30% drop indicates potential DIC even if absolute count remains normal 3