Heparin and tranexamic Acid therapy may be effective in treatment-resistant chronic urticaria with elevated D-dimer : a pilot study

Background : chronic urticaria (CU) patients often present activation of the coagulation cascade and fibrinolysis whose markers correlate with disease severity. Aim : we evaluated whether CU patients with elevated plasma D-dimer have a poor response to antihistamines, and anticoagulation and inhibition of fibrinolysis may be beneficial in these patients. Methods : sixty-eight consecutive patients with CU were prescribed cetirizine 10 mg daily for 2 weeks; plasma D-dimer was measured. Non-responders were given cetirizine 30 mg daily for 1 week and subsequently, in case of failure, systemic steroids. Patients with persistent controlled CU and elevated D-dimer plasma levels were offered subcutaneous nadroparin 11,400 IU once a day and oral tranexamic acid 1 g three times a day for 2 weeks. Results : D-dimer levels were elevated in 14/68 (20.6%) patients (range 306–7,317 ng/ml; normal values ! 278 ng/ml) and were associated with a more severe disease. Twelve of 14 patients with elevated D-dimer levels did not respond to antihistamine treatment (p = 0.0001). On the whole, 14 patients reported a poor or absent response to cetirizine 10 mg daily and only 1 of these responded satisfactorily to cetirizine 30 mg daily. Eight patients with elevated D-dimer and whose disease was not satisfactorily controlled by prednisone received nadroparin and tranexamic acid. A marked improvement of symptoms was observed in 5/8 cases. Conclusion : our findings indicate that CU patients with elevated D-dimer often present a more severe disease with reduced response to antihistamines. Based on this short pilot study, some of these patients may benefit from treatment with nadroparin and tranexamic acid