From the Guidelines
For patients with low fibrinogen, also known as hypofibrinogenemia, fibrinogen replacement therapy is recommended, typically with cryoprecipitate or fibrinogen concentrate, when fibrinogen levels are below 1.5 g/L, as suggested by the most recent and highest quality study 1.
Key Points to Consider
- Fibrinogen is a protein essential for blood clotting, and low levels can lead to bleeding complications.
- The standard dose of fibrinogen concentrate is 70 mg/kg, while cryoprecipitate is dosed at 1 unit per 5-10 kg body weight.
- Treatment should continue until fibrinogen levels reach at least 100 mg/dL or bleeding stops.
- Patients should avoid activities with high risk of injury, take precautions during dental procedures, and be cautious with medications that affect blood clotting like aspirin or NSAIDs.
- Regular monitoring of fibrinogen levels is important, especially before surgical procedures.
Causes and Management
- Low fibrinogen can be congenital (inherited) or acquired from conditions like liver disease, severe infections, certain cancers, or consumption during massive bleeding events.
- Understanding the underlying cause is crucial for appropriate long-term management.
- The European guideline on management of major bleeding and coagulopathy following trauma suggests early fibrinogen administration, ideally guided by a fibrinogen concentration < 1.5 g/L or viscoelastic evidence of a functional fibrinogen deficiency 1.
Treatment Options
- Fibrinogen replacement therapy with cryoprecipitate or fibrinogen concentrate is recommended for severe cases or active bleeding.
- Prothrombin complex concentrates (PCC) may be used in addition to fibrinogen administration, but their use should be guided by viscoelastic testing and careful clinical monitoring 1.
- The use of PCC should be avoided in patients with normal fibrinogen levels, as it may increase the risk of thromboembolic events.
- Viscoelastic monitoring, such as thromboelastometry, can help guide individualized goal-directed coagulation therapy in patients with traumatic coagulopathy 1.
From the Research
Dic low Fibrinogen
- Dic low fibrinogen, also known as disseminated intravascular coagulation (DIC) with low fibrinogen levels, is a condition characterized by the depletion of fibrinogen, leading to an increased risk of coagulopathy, further bleeding, and transfusion requirements 2.
- Fibrinogen levels less than 150 mg/dL have been associated with increased rates of bleeding and lower survival in critically ill cirrhosis patients 3.
- Treatment with cryoprecipitate for low fibrinogen levels does not affect bleeding or survival in critically ill cirrhosis patients 3.
Fibrinogen Concentrate vs Cryoprecipitate
- Fibrinogen concentrate and cryoprecipitate are both used to replenish low plasma fibrinogen levels, but the available evidence directly comparing the two is sparse and with high risk of bias 2.
- A systematic review found that fibrinogen concentrate and cryoprecipitate had similar effects on fibrinogen-level increase, bleeding, RBC transfusions, and thromboembolic complications, but cryoprecipitate may have a possible increased functional improvement of haemostasis 2.
- Another study found that fibrinogen supplementation in the form of fibrinogen concentrate was associated with improved outcomes and reduced transfusion requirements compared to cryoprecipitate in traumatic hemorrhagic patients 4.
Efficacy of Fibrinogen Concentrates
- Fibrinogen concentrates have been shown to reduce bleeding and transfusion requirements in bleeding patients, primarily in elective cardiac surgery, but the evidence is weak and more randomized controlled trials are needed 5.
- A study comparing the efficacy of cryoprecipitate and fibrinogen concentrates found that cryoprecipitate and one of the fibrinogen concentrates (FibCLOT®) produced clots with higher maximal absorbance and enhanced resistance to lysis, while the other fibrinogen concentrate (RiaSTAP®) showed stunted fibers and reduced porosity 6.
Clinical Implications
- The choice between fibrinogen concentrate and cryoprecipitate for fibrinogen supplementation should be based on individual patient needs and clinical judgment, as the current evidence does not support the recommendation of one product over the other 2, 4.
- Further research is needed to guide evidence-based decisions on the use of fibrinogen concentrates and cryoprecipitate in clinical practice 2, 5, 4.