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

From the Guidelines

For the treatment of Disseminated Intravascular Coagulation (DIC), the primary approach should focus on managing the underlying cause, with guidance from the most recent and highest quality studies suggesting that appropriate treatment of the underlying condition is crucial. In the context of cancer-associated DIC, we recommend appropriate treatment of the underlying cancer as the first-line strategy 1. This approach is supported by the guidance from the SSC of the ISTH, emphasizing the importance of addressing the root cause of DIC.

When it comes to supportive measures for patients with DIC and active bleeding, or those at high risk of bleeding, the following strategies are suggested:

• In patients with DIC and active bleeding, platelet transfusion is recommended to maintain the platelet count above 50 × 10^9/L 1.
• For patients with DIC who are at high risk of bleeding, transfusion of one to two doses of platelets is suggested if the platelet count is less than 30 × 10^9/L in Acute Promyelocytic Leukemia (APL) and less than 20 × 10^9/L in other cancers 1.
• Transfusion of fresh frozen plasma (15–30 mL/kg) with careful clinical monitoring is recommended for patients with DIC and active bleeding 1. In cases where volume overload is a concern, the use of prothrombin complex concentrates is suggested 1.
• For actively bleeding cases with persistently low fibrinogen values (below 1.5 g/L) despite supportive measures, transfusion of two pools of cryoprecipitate (whenever available) or fibrinogen concentrate is recommended 1.

It's also important to consider the role of anticoagulation in the management of cancer-related DIC. Prophylactic anticoagulation is recommended in all patients with cancer-related DIC, except in cases of hyperfibrinolytic DIC, and in the absence of contraindications 1. Therapeutic-dose anticoagulation should be used in those who develop arterial or venous thrombosis in this context.

Regular clinical and laboratory surveillance is crucial to assess the improvement or worsening of the patient's condition, detect the development of complications, and ensure that the underlying condition is being adequately treated 1.

From the FDA Drug Label

HEPARIN SODIUM INJECTION, for intravenous or subcutaneous use Initial U. S INJECTION is an anticoagulant indicated for (1) • Prophylaxis and treatment of venous thrombosis and pulmonary embolism

Table 1: Recommended Adult Full-Dose Heparin Regimens for Therapeutic Anticoagulant Effect *Based on 68 kg patient METHOD OF ADMINISTRATION FREQUENCY RECOMMENDED DOSE Deep Subcutaneous (Intrafat) Injection Use a different site for each injection to prevent the development of hematoma Initial Dose 5,000 units by intravenous injection, followed by 10,000 to 20,000 units of a concentrated solution, subcutaneously Every 8 hours or 8,000 to 10,000 units of a concentrated solution Every 12 hours 15,000 to 20,000 units of a concentrated solution

The treatment for DIC (Disseminated Intravascular Coagulation) using heparin includes administering 10,000 to 20,000 units of a concentrated solution subcutaneously every 8 or 12 hours, or through intermittent intravenous injection with an initial dose of 10,000 units. The dosage may be adjusted according to the patient's coagulation test results, with the goal of achieving a therapeutic anticoagulant effect 2 2. Key considerations include:

• Monitoring the patient's coagulation status and adjusting the dosage accordingly
• Periodic monitoring of platelet counts, hematocrit, and occult blood in stool during the entire course of heparin therapy
• Using a preservative-free formulation in neonates and infants
• Avoiding the intramuscular route of administration due to the risk of hematoma at the injection site.

From the Research

Dic Treatment Overview

• Disseminated intravascular coagulation (DIC) is a syndrome caused by the systemic generation of thrombin, and its treatment is aimed at combating the underlying disorder followed by supportive management 3, 4.
• The most common clinical manifestation of DIC is bleeding, with thrombosis in less than 10% of acute cases but more frequently encountered in chronic DIC associated with malignancy 3.
• Acute DIC must first be treated by specific therapy of the underlying disease and general support measures, and if serial clinical and laboratory monitoring improves, no further treatment is required 3.

Treatment Approaches

• If severe or life-threatening haemorrhage occurs or a thrombotic event ensues, heparin anticoagulation followed by aggressive replacement with platelets, fresh plasma and possibly cryoprecipitate is indicated 3.
• Low molecular weight heparin is advocated in special situations, whereas anti-thrombin III and activated protein C are of doubtful value 4.
• Treatment with activated protein C (APC) reduced 28-day mortality of patients with severe sepsis, including patients retrospectively assigned to a subgroup with sepsis-associated DIC, but increased the bleeding risk in patients with sepsis 5.
• Clinical studies with recombinant tissue factor pathway inhibitor (TFPI) or thrombomodulin (TM) have been carried out showing promising results 5.

Management and Diagnosis

• The International Society on Thrombosis and Haemostasis (ISTH) established a DIC diagnostic scoring system consisting of global haemostatic test parameters, which has now been well validated in diverse clinical settings 6.
• The theoretical cornerstone of DIC management is the specific and vigorous treatment of the underlying conditions, and DIC should be simultaneously managed to improve patient outcomes 6.
• Diagnosis of DIC should be made only in the presence of a causative factor supported by repeated laboratory tests for coagulation profile and clotting factors 4.