What is the management of disseminated intravascular coagulation (DIC)?

Management of Disseminated Intravascular Coagulation (DIC)

The fundamental management of DIC requires immediate treatment of the underlying disease process combined with supportive care using blood product transfusions at specific thresholds, and prophylactic anticoagulation with heparin in most cases except when hyperfibrinolysis or active bleeding predominates. 1, 2, 3

Treat the Underlying Cause First

The cornerstone of DIC management is addressing the triggering condition, as DIC is always secondary to an underlying process. 1, 2, 3

• In cancer-associated DIC: Initiate appropriate cancer therapy immediately (chemotherapy, surgery, or radiation). 3
• In acute promyelocytic leukemia (APL): Early commencement of all-trans retinoic acid achieves good resolution of DIC. 1, 3
• In sepsis-associated DIC: Source control and appropriate antibiotics are essential. 3
• In solid tumors: Treatment of the malignancy is fundamental for DIC resolution. 2

Regular Laboratory Monitoring

Establish baseline coagulation status and monitor regularly to guide therapy. 1, 2, 3

• Monitor: Complete blood count, PT/aPTT, fibrinogen, and D-dimer. 1, 2, 3
• Frequency: Varies from daily in acute severe DIC to monthly in chronic stable cases, decided case-by-case. 1, 2, 3
• Key diagnostic threshold: A ≥30% drop in platelet count indicates subclinical DIC even when absolute values remain normal. 1, 2, 3

Important caveat: PT and aPTT may not be prolonged in cancer-associated DIC, especially subclinical forms, when coagulation factors are only moderately decreased. 1

Supportive Care with Blood Products

Platelet Transfusion Thresholds

• Active bleeding: Transfuse to maintain platelets >50×10⁹/L. 1, 2, 3, 4
• High bleeding risk without active bleeding (surgery/invasive procedures):
  • APL: Transfuse if platelets <30×10⁹/L. 1, 2
  • Other cancers: Transfuse if platelets <20×10⁹/L. 1, 2
  • Non-cancer DIC: Use 20-30×10⁹/L threshold. 4

Critical warning: The lifespan of transfused platelets may be very short in DIC with vigorous coagulation activation and fibrinolysis. 1, 2, 5

Fresh Frozen Plasma (FFP)

• Active bleeding with prolonged PT/aPTT: Administer 15-30 mL/kg of FFP with careful clinical monitoring. 1, 2, 3
• Volume overload concerns: Use prothrombin complex concentrates instead. 1

Important note: Do not transfuse FFP based solely on laboratory abnormalities without bleeding. 6

Fibrinogen Replacement

• Persistent hypofibrinogenemia (<1.5 g/L) despite FFP: Transfuse two pools of cryoprecipitate (when available) or fibrinogen concentrate. 1, 2, 3
• Severe hypofibrinogenemia (<1.0 g/L): Indicates severe consumption requiring replacement. 5

Anticoagulation Strategy

Prophylactic Anticoagulation

Initiate prophylactic heparin in all DIC patients except those with hyperfibrinolytic DIC, active bleeding, or platelets <20-30×10⁹/L. 1, 2, 3, 4

• First choice: Low molecular weight heparin (LMWH) for most patients. 2, 3
• Alternative: Unfractionated heparin (UFH) if high bleeding risk and renal failure exist (due to reversibility). 2
• Contraindications: Platelet count <20×10⁹/L or active bleeding. 1, 2

Therapeutic Anticoagulation

Escalate to therapeutic-dose anticoagulation when thrombosis predominates: 1, 3, 6

• Indications: Arterial or venous thromboembolism, severe purpura fulminans with acral ischemia, or vascular skin infarction. 6
• Solid tumors with thromboembolism: LMWH at therapeutic dose for 6 months (first month at full dose, then 75% dose for 5 months) is superior to warfarin. 2
• Procoagulant DIC: Common in pancreatic cancer and adenocarcinomas, presenting with arterial ischemia or venous thromboembolism. 3

When to Avoid Heparin

Do not use heparin in hyperfibrinolytic DIC. 2

• Hyperfibrinolytic DIC: Typical of APL and metastatic prostate cancer, presenting with widespread bleeding from multiple sites. 3
• Consider antifibrinolytic therapy (tranexamic acid) in these cases with severe bleeding. 6

FDA-Approved Indication

Heparin Sodium Injection is FDA-approved for "treatment of acute and chronic consumptive coagulopathies (disseminated intravascular coagulation)." 7

Special Considerations and Pitfalls

• Normal platelet count does not exclude DIC: A profound decrease from very high baseline levels may still be in the normal range but indicates ongoing DIC. 1
• Coagulation abnormalities alone are not absolute contraindications to anticoagulation in the absence of active bleeding. 2
• Fibrinogen depletes first in massive transfusion scenarios, reaching critical levels after approximately 150% blood volume loss. 5
• Metastatic disease with poor prognosis: Tailor interventions based on physician discretion, patient preferences, and available resources. 1