Disseminated Intravascular Coagulation Medication

Updated: Sep 29, 2016
  • Author: Marcel M Levi, MD; Chief Editor: Srikanth Nagalla, MBBS, MS, FACP  more...
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Medication

Medication Summary

The goals of pharmacotherapy in cases of disseminated intravascular coagulation (DIC) are to reduce morbidity and to prevent complications. Therapy should be based on etiology and aimed at eliminating the underlying disease. Treatment should be appropriately aggressive for the patient’s age, disease, and severity and location of hemorrhage or thrombosis. Treatment of acute DIC includes anticoagulants, blood components, and antifibrinolytics. Hemostatic and coagulation parameters should be monitored continuously during treatment.

Base therapeutic decisions on clinical and laboratory evaluation of hemostasis. In cases of low-grade DIC, therapy other than supportive care may not be warranted or may include antiplatelet agents or subcutaneous heparin; treatment decisions should be based on clinical and laboratory evaluation of hemostasis.

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Anticoagulants, Hematologic

Class Summary

Anticoagulants are used in the treatment of clinically evident intravascular thrombosis when the patient continues to bleed or clot 4-6 hours after initiation of primary and supportive therapy. Thrombosis can present as purpura fulminans or acral ischemia. Take special precaution in obstetric emergencies or massive liver failure. The anti-inflammatory properties of antithrombin may be particularly useful in DIC secondary to sepsis.

Heparin is the only currently available antithrombotic drug that has a role in the treatment of patients with DIC. Although most experience is with standard heparin, low-molecular-weight heparins (LMWHs) are increasingly used. Moreover, although LMWHs usually do not require laboratory monitoring, it may be advisable to check anti-factor Xa levels in critically ill patients with serious renal failure.

Heparin

Heparin augments the activity of antithrombin and prevents conversion of fibrinogen to fibrin. It does not actively lyse but is able to inhibit further thrombogenesis. It prevents reaccumulation of clot after spontaneous fibrinolysis. Usage and dosing of heparin are based on the severity of DIC, the underlying cause, and the extent of thrombosis. Monitoring the results of therapy is mandatory.

Antithrombin (Atryn, Thrombate III)

Antithrombin is used for moderately severe–to–severe DIC or when levels are depressed markedly. It is an alpha2-globulin that inactivates thrombin, plasmin, and other serine proteases of coagulation, including factors IXa, Xa, XIa, XIIa, and VIIa. These effects inhibit coagulation.

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Recombinant Human Activated Protein C

Class Summary

Recombinant human APC inhibits factors Va and VIIIa of the coagulation cascade. It may also inhibit plasminogen activator inhibitor-1 (PAI-1). Drotrecogin alfa (Xigris) was withdrawn from the worldwide market on October 25, 2011.

Drotecogin alfa (Xigris)

Withdrawn from the worldwide market on October 25, 2011. Drotrecogin alfa was approved for the reduction of mortality in patients who have severe sepsis associated with acute organ dysfunction and who are at high risk for death. It is a recombinant form of human APC that exerts an antithrombotic effect by inhibiting factors Va and VIIIa.

Drotrecogin alfa exercises indirect profibrinolytic activity by inhibiting PAI-1 and limiting formation of activated thrombin-activatable fibrinolysis inhibitor. It may exert an anti-inflammatory effect by inhibiting human tumor necrosis factor (TNF) production by monocytes, blocking leukocyte adhesion to selectins, and limiting thrombin-induced inflammatory responses within the microvascular endothelium.

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Blood Components

Class Summary

Blood components are used to correct abnormal hemostatic parameters. These products should be considered only after initial supportive and anticoagulant therapy. Washed packed red blood cells (PRBCs) and platelet concentrates are considered safe in uncontrolled DIC. Specialized blood components (eg, cryoprecipitate and fresh frozen plasma [FFP]) may interfere with or alleviate DIC.

Packed red blood cells (PRBCs; washed)

PRBCs are preferred to whole blood because they limit volume, immune, and storage complications. Obtain PRBCs after centrifugation of whole blood. Use washed or frozen PRBCs in individuals with hypersensitivity transfusion reactions.

Platelets

Platelets are considered safe for use in acute DIC.

Fresh frozen plasma (FFP)

FFP treatment entails removing blood from the body, spinning it to separate cells from plasma, and replacing cells suspended in fresh frozen plasma, albumin, or saline. FFP contains coagulation factors, as well as protein C and protein S. It can be administered either via 2 large-bore peripheral intravenous lines or via 1 multiple-lumen central line. It is recommended for patients with active bleeding and a fibrinogen level below 100 mg/dL.

Cryoprecipitate or fibrinogen concentrates

Cryoprecipitate and fibrinogen concentrates are not commonly recommended, except when fibrinogen is needed.

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Antifibrinolytic Agents

Class Summary

In general, antifibrinolytic agents should be avoided in DIC because they are known to produce thrombotic complications, such as myocardial infarction and renal artery thrombosis when there is systemic clotting. They may have a role in a local intravascular coagulation (LIC) as is seen in genitourinary bleeding after a transurethral resection for Kasabach-Merritt syndrome.

In addition, in patients with trauma and massive bllood loss, antifibrinolytic agents have been shown to be effective in reducing blood loss and improving survival. [87] Similarly, in massive postpartum hemorrhage, antifibrinolytic agents have been shown to be effective. [88] Antifibrinolytics also may be useful in cases of DIC secondary to hyperfibrinolysis associated with acute promyelocytic leukemia and other forms of cancer when alpha-2-antiplasmin is uniquely decreased.

Aminocaproic acid (Amicar)

Aminocaproic acid inhibits fibrinolysis by inhibiting plasminogen activators and, to a lesser degree, exerting antiplasmin activity. The main problem is that the thrombi that form during treatment are not lysed and that the clinical significance of reducing bleeding is uncertain.

Tranexamic acid (Cyklokapron, Lysteda)

Tranexamic acid is used as an alternative to aminocaproic acid. It inhibits fibrinolysis by displacing plasminogen from fibrin.

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