What is the preferred treatment approach with Fresh Frozen Plasma (FFP), heparin, or Low Molecular Weight Heparin (LMWH) in managing Disseminated Intravascular Coagulation (DIC)?

Management of DIC: FFP vs Heparin vs LMWH

The optimal treatment strategy for DIC prioritizes treating the underlying condition first, followed by prophylactic anticoagulation with LMWH (or UFH in specific circumstances), while reserving FFP for active bleeding with prolonged coagulation times—not as primary therapy. 1, 2

Treatment Hierarchy

First-Line: Treat the Underlying Condition

• Addressing the underlying trigger is the absolute cornerstone of DIC management and takes precedence over all other interventions. 1, 2, 3
• Examples include cancer treatment, sepsis management, or surgical source control 2, 3
• In acute promyelocytic leukemia, early induction therapy achieves excellent DIC resolution 1, 2

Second-Line: Anticoagulation Strategy

When to Use Heparin/LMWH:

• Prophylactic anticoagulation is recommended in all DIC patients EXCEPT those with hyperfibrinolytic DIC, unless contraindications exist. 1, 2
• Contraindications include active bleeding, platelets <20×10⁹/L (some sources suggest <30×10⁹/L), or hyperfibrinolytic DIC 1, 2, 4
• Therapeutic-dose anticoagulation is indicated when arterial or venous thrombosis develops 1

LMWH vs UFH Selection:

• LMWH is preferred in most cases due to better pharmacokinetics and ease of administration. 1, 2, 5
• UFH is chosen when high bleeding risk exists or in renal failure due to easier reversibility with protamine. 1, 2, 3
• In cardiac surgery patients, UFH is preferred due to short half-life and reversibility 3
• Monitoring UFH via aPTT may be problematic since aPTT is already prolonged in DIC; consider anti-FXa assays 1

Third-Line: Blood Product Support (Reserved for Bleeding)

FFP Indications:

• FFP should be administered at 15-30 mL/kg ONLY in patients with active bleeding and prolonged PT/aPTT, not based on laboratory abnormalities alone. 1, 2, 6, 4
• FFP is NOT first-line therapy and should not be given prophylactically 6, 4
• If volume overload is a concern, consider prothrombin complex concentrates instead 1

Platelet Transfusion Thresholds:

• Active bleeding: maintain platelets >50×10⁹/L 1, 2, 6, 4
• High bleeding risk without active bleeding: transfuse if <30×10⁹/L in APL or <20×10⁹/L in other cancers 1, 2, 6
• Non-bleeding patients: prophylactic transfusion generally not recommended unless very high bleeding risk 6, 4

Fibrinogen Replacement:

• If fibrinogen remains <1.5 g/L despite FFP in actively bleeding patients, give cryoprecipitate (two pools) or fibrinogen concentrate 1, 2, 6

Critical Clinical Scenarios

DIC with Predominant Thrombosis

• Use therapeutic-dose heparin for arterial/venous thromboembolism, severe purpura fulminans with acral ischemia, or vascular skin infarction 6, 7
• Weight-adjusted UFH (e.g., 10 units/kg/h) may be used without targeting specific aPTT prolongation 6
• In chronic DIC with thrombosis (especially malignancy), warfarin is ineffective; long-term subcutaneous heparin may be required 7

DIC with Predominant Bleeding

• Abnormal coagulation tests alone should NOT be considered an absolute contraindication to anticoagulation in the absence of active bleeding. 1, 2
• Aggressive blood product replacement (FFP, platelets, cryoprecipitate) is indicated for severe or life-threatening hemorrhage 6, 7
• Heparin may still be considered after initial hemostatic support to prevent ongoing thrombin generation 7

Hyperfibrinolytic DIC

• Avoid heparin in hyperfibrinolytic DIC. 1, 2
• Tranexamic acid is NOT routinely recommended due to lack of benefit and increased thrombotic risk 1, 2
• Consider tranexamic acid only if therapy-resistant bleeding dominates despite other measures 1, 3

Common Pitfalls

• Do not transfuse FFP or platelets based solely on laboratory values without clinical bleeding or high bleeding risk. 6, 4
• The lifespan of transfused platelets and fibrinogen may be extremely short in DIC with vigorous coagulation activation 1, 2
• Coagulation tests (PT/aPTT) may be normal in subclinical DIC, especially cancer-associated; monitor for 30% platelet drop 1, 2
• Recombinant FVIIa cannot be recommended due to lack of RCT evidence and significant thrombotic risk 1
• Anticoagulant concentrates (antithrombin, activated protein C, thrombomodulin) lack evidence for cancer-related DIC 1

Monitoring Requirements

• Regular monitoring of CBC, PT/aPTT, fibrinogen, and D-dimer is essential 1, 2, 3
• Frequency ranges from daily in acute DIC to monthly in chronic cases, adjusted case-by-case 1, 2
• Monitor for complications including organ failure and adequacy of underlying disease treatment 1