What is the recommended treatment for disseminated intravascular coagulation?

Treatment of Disseminated Intravascular Coagulation (DIC)

The cornerstone of DIC treatment is aggressive management of the underlying trigger (sepsis, malignancy, trauma, obstetric complications), combined with supportive transfusion therapy guided by clinical bleeding and specific laboratory thresholds—not laboratory abnormalities alone. 1, 2, 3

Immediate Priority: Treat the Underlying Cause

• Identify and aggressively treat the precipitating condition as the primary therapeutic goal, as DIC will not resolve without addressing the root cause. 1, 3, 4
• Common triggers requiring immediate intervention include:
  • Sepsis: source control and appropriate antibiotics 3
  • Malignancy: early chemotherapy (particularly crucial in acute promyelocytic leukemia where it achieves excellent DIC resolution) 1, 3
  • Trauma: surgical intervention and hemorrhage control 3
  • Obstetric complications: delivery, management of eclampsia, or surgical exploration for retained products 3, 5

Classify the Clinical Phenotype

Determine whether the patient has bleeding-predominant, thrombosis-predominant, or hyperfibrinolytic DIC, as this classification fundamentally guides therapy. 2, 3

For Bleeding-Predominant DIC:

Transfusion Support (Only for Active Bleeding or High Procedural Risk)

• Platelets: Maintain >50 × 10⁹/L in actively bleeding patients or those requiring invasive procedures. 2, 3, 6

  • In non-bleeding high-risk patients: transfuse if <30 × 10⁹/L for acute promyelocytic leukemia or <20 × 10⁹/L for other malignancies. 2
  • Critical caveat: Transfused platelets have very short survival in active DIC due to ongoing consumption, often requiring repeated dosing. 2, 5

• Fresh Frozen Plasma (FFP): Administer 15–30 mL/kg for prolonged PT/aPTT with active bleeding. 2, 3, 6

  • Dose adjustments should be guided by clinical response rather than isolated coagulation test prolongation. 2
  • When volume overload is a concern, prothrombin complex concentrates may replace plasma, though they provide only selected clotting factors. 2

• Fibrinogen Replacement: When fibrinogen remains <1.5 g/L despite FFP, administer two pools of cryoprecipitate or fibrinogen concentrate. 2, 3, 6

• Do NOT transfuse based solely on laboratory abnormalities in the absence of clinical bleeding or planned high-risk procedures. 2, 5, 6

For Thrombosis-Predominant DIC:

Anticoagulation Therapy

• Initiate therapeutic-dose heparin for arterial/venous thromboembolism, severe purpura fulminans with acral ischemia, or vascular skin infarction. 2, 3, 6

• In cancer-associated DIC without active bleeding: Consider prophylactic anticoagulation unless contraindicated (platelets <20 × 10⁹/L or active bleeding). 1, 3

  • For solid tumor-associated thromboembolism: use therapeutic-dose low-molecular-weight heparin (LMWH) for 6 months (full dose for 1 month, then 75% dose for 5 months). 2

• Choice of heparin formulation:

  • LMWH is preferred in most cases. 2, 5
  • Unfractionated heparin (UFH) is preferred when rapid reversibility is needed (high bleeding risk or renal impairment). 2, 5, 7

• Critical principle: Abnormal PT/aPTT alone should NOT preclude anticoagulation in the absence of bleeding, as DIC reflects a rebalanced hemostatic state with simultaneous loss of pro- and anticoagulant factors. 2, 6

For Hyperfibrinolytic DIC:

• Avoid heparin entirely, as it can exacerbate bleeding in this phenotype. 2, 8

• Tranexamic acid is NOT routinely recommended and may increase thrombotic events. 1, 5

  • Reserve tranexamic acid ONLY for therapy-resistant bleeding with documented hyperfibrinolysis. 1, 5

Agents That Should NOT Be Used

• Recombinant Factor VIIa: Not recommended due to uncertain benefit and definite thrombotic risk. 1, 5
• Corticosteroids: No established benefit in DIC. 2, 5
• Antiplatelet agents: Not indicated and may increase bleeding risk. 2, 5

Monitoring Strategy

• Serial laboratory assessment is essential: CBC, PT/aPTT, fibrinogen, and D-dimer. 1, 3
• Frequency should be adjusted to clinical severity (daily in acute DIC, less frequent as patient stabilizes). 3
• A ≥30% drop in platelet count may indicate worsening DIC even if absolute values remain normal. 2, 3, 5
• Monitor for complications including organ failure and ensure the underlying condition is being adequately treated. 1

Common Pitfalls to Avoid

• Do NOT transfuse solely to correct laboratory values without clinical bleeding or procedural indication. 2, 5, 6
• Do NOT withhold anticoagulation in thrombotic DIC solely because of prolonged PT/aPTT. 2, 6
• Do NOT use antifibrinolytics routinely; they are reserved for refractory bleeding with documented hyperfibrinolysis. 1, 5
• Recognize that transfused blood products have reduced survival in active DIC, often requiring repeated administrations. 2, 5
• In cancer-associated DIC, avoid heparin in hyperfibrinolytic phenotype but use prophylactic anticoagulation in other phenotypes unless contraindicated. 1

Special Considerations for Complex Scenarios

New thrombosis with severe thrombocytopenia (<25–50 × 10⁹/L): Options include platelet transfusions plus therapeutic anticoagulation, intermediate-dose anticoagulation without transfusions, or no anticoagulation unless the thrombus is in a critical location (e.g., pulmonary embolism). 1