What is the treatment for disseminated intravascular coagulation (DIC) in a patient who developed it after chemotherapy?

Treatment of Disseminated Intravascular Coagulation After Chemotherapy

The cornerstone of treating chemotherapy-associated DIC is aggressive treatment of the underlying malignancy with simultaneous supportive hemostatic therapy guided by bleeding status and specific laboratory thresholds. 1, 2

Immediate Treatment Priorities

1. Treat the Underlying Cancer First

• Early initiation or continuation of cancer-directed chemotherapy is the most critical intervention and achieves good resolution of DIC, particularly in acute promyelocytic leukemia. 1, 2
• In APL specifically, early commencement of induction therapy results in excellent DIC resolution. 1
• Case reports demonstrate that systemic chemotherapy alone can completely resolve DIC after one cycle, even without specific anti-DIC therapies. 3

2. Classify the DIC Phenotype

Before initiating supportive measures, determine which of three DIC subtypes is present, as this guides management: 1, 2

• Procoagulant DIC: Predominant thrombosis (common in pancreatic cancer, adenocarcinomas)
• Hyperfibrinolytic DIC: Predominant bleeding (seen in APL, metastatic prostate cancer)
• Subclinical DIC: Laboratory abnormalities without overt clinical manifestations

Supportive Hemostatic Management

For Active Bleeding:

• Maintain platelet count >50×10⁹/L with platelet transfusions. 1, 2
• Administer fresh frozen plasma 15-30 mL/kg for prolonged PT/aPTT. 1, 2
• Replace fibrinogen if <1.5 g/L persists despite FFP using cryoprecipitate (two pools) or fibrinogen concentrate. 1, 2
• Monitor carefully as transfused platelets and fibrinogen may have very short lifespans due to vigorous coagulation activation. 1

For High Bleeding Risk Without Active Bleeding:

• Transfuse platelets if count is <30×10⁹/L in APL or <20×10⁹/L in other cancers. 1, 2
• Consider one to two doses of platelets (from five donors or equivalent) before invasive procedures. 1

Critical Caveat:

If volume overload is a concern with FFP administration, use prothrombin complex concentrates instead. 1

Anticoagulation Strategy

Prophylactic Anticoagulation:

• Administer prophylactic anticoagulation in all patients with cancer-related DIC EXCEPT hyperfibrinolytic DIC, unless contraindications exist. 1, 2
• Heparin is primarily indicated for thrombotic-predominant (procoagulant) DIC. 2, 4
• Case reports demonstrate successful use of subcutaneous unfractionated heparin or low molecular weight heparinoids in chemotherapy-associated DIC. 5, 6

Therapeutic Anticoagulation:

• Use therapeutic-dose anticoagulation for patients who develop arterial or venous thrombosis, severe purpura fulminans with acral ischemia, or vascular skin infarction. 1, 2
• In solid tumors with thromboembolic events, low molecular weight heparin at therapeutic doses for 6 months is superior to warfarin. 4

Contraindications:

• Do NOT use anticoagulation in hyperfibrinolytic DIC. 1, 4
• Avoid if platelets <20×10⁹/L or active uncontrolled bleeding is present. 4

Monitoring Protocol

• Monitor CBC, PT/aPTT, fibrinogen, and D-dimer daily in acute DIC. 2
• Adjust monitoring frequency from daily to monthly based on clinical stability. 1, 2
• A 30% or greater drop in platelet count indicates subclinical DIC progression, even if the absolute count remains normal—this is crucial in patients with initially elevated platelet counts from malignancy. 1, 2
• Regular surveillance is essential to detect complications including organ failure and assess whether the underlying cancer is being adequately treated. 1

Agents to Avoid

• Do NOT routinely use tranexamic acid or recombinant Factor VIIa. 1
• Tranexamic acid may only be considered if therapy-resistant bleeding dominates in hyperfibrinolytic DIC, but carries thrombotic risks. 1

Special Considerations for Chemotherapy-Associated DIC

• Marrow failure and chemotherapy effects can independently affect platelet counts in hematological cancers, making trend analysis more important than absolute values. 1
• PT and PTT may not be prolonged in subclinical cancer-associated DIC when coagulation factors are only moderately decreased. 1
• Tumor lysis syndrome following chemotherapy can release large amounts of tissue factor, potentially inducing DIC—clinicians should anticipate this in advanced small cell lung cancer and other highly chemosensitive tumors. 5
• Choose chemotherapy regimens with mild bone marrow suppression when possible, considering delayed hematologic toxicity and the possibility of DIC relapse during drug withdrawal periods. 7