About Coach’s Corner
In the best of all worlds, clinical practice guidelines provide recommendations about diagnosis and treatment that are based on solid evidence from phase 3 clinical trials. In many cases, such evidence does not exist and recommendations are provided based on expert opinion. Even then, many questions pertinent to clinical care may be left out of guidelines. In Coach’s Corner, we aim to address some of these gaps by surveying the opinion of clinical experts from the TBP board of advisors in areas where there exists a gray zone. This exercise is not meant to provide definitive guidance for patient care, but rather is designed to highlight the importance of clinical experience and critical thinking in the decision making process.
The opinions presented in this case were obtained in May 2022, and may be subject to change as new evidence emerges.
Background: Clinical practice guidelines recommend using a scoring system rather than clinical gestalt for diagnosing disseminated intravascular coagulation (DIC).
Question: Do you routinely use a clinical scoring system for diagnosing DIC, and if not, why?
Background: The clinical scoring systems include parameters that are altered at baseline in chronic liver disease.
We asked our experts:
Question: How do you make a diagnosis of DIC in a patient with cirrhosis? How helpful are FVIII levels in differentiating between the 2 conditions?
Diagnosis of DIC in a patient with cirrhosis can be very challenging. In my experience, FVIII activity is often higher in liver disease, but it can be elevated in DIC as an acute phase reactant and is not very helpful in discriminating between DIC and cirrhosis (unless FVIII levels are low, which is more consistent with DIC). The clinical context is key.
In a sick/advanced/decompensated liver disease, this may be difficult. To complicate it, these patients may have sepsis or another reason to have DIC, but there may also be some consumptive coagulopathy in liver disease as well which is considered a vasculopathy by many. I feel everything that has been described to differentiate between the two diagnoses is arbitrary, and at the end of the day, what matters is that you treat coagulopathy when indicated in both the cases. Factor VIII is elevated in both conditions.
Background: Clinical practice guidelines recommend replacement therapies (platelets, fresh frozen plasma [FFP], cryoprecipitate) only if the patient is bleeding or is at increased risk of bleeding (for example, undergoing an invasive procedure). Yet it is not unusual to see replacement therapies targeted towards numbers (PT, fibrinogen and platelet count) regardless of the bleeding status/risk of the patient.
We asked our experts:
Question: Under what conditions do you recommend replacement therapies in DIC?
In a non-bleeding patient who does not require an invasive procedure, I transfuse platelets to 10,000 and FFP to fibrinogen > 100. For a patient who is bleeding or who needs an urgent procedure, I transfuse platelets to 50,000 (or whatever threshold for procedure is) and may also increase fibrinogen goal. I use a higher fibrinogen goal (> 300) in pregnant and immediately postpartum patients given that the normal increase in fibrinogen near term can mask DIC.
Background: Harmonization of the recommendations from three guidelines on DIC state the following: “Therapeutic doses of heparin should be considered in cases of DIC where thrombosis predominates (low quality). The use of low molecular weight heparin (LMWH) is preferred to the use of unfractionated heparin (UFH) in these cases (low quality).” Yet heparin therapy is not widely used for DIC, at least in the United States.
Question: Under what conditions do you recommend the use of therapeutic doses of heparin in DIC, and what dose do you actually use?