Can epistaxis (nosebleed) be fatal in patients on anticoagulants (blood thinners)?

From the Guidelines

Yes, epistaxis (nosebleed) can potentially be fatal in patients taking anticoagulants, though this is rare. Anticoagulant medications such as warfarin, apixaban, rivaroxaban, dabigatran, and heparin increase bleeding risk by interfering with normal blood clotting mechanisms, as noted in the clinical practice guideline: nosebleed (epistaxis) 1. In patients on these medications, what might otherwise be a minor nosebleed can become prolonged and difficult to control, potentially leading to significant blood loss. Severe cases can result in hemodynamic instability, hypovolemic shock, and even death if not properly managed.

Management of Epistaxis in Patients on Anticoagulants

Patients on anticoagulants who experience nosebleeds should apply direct pressure to the nose by pinching the soft part of the nostrils together for at least 10-15 minutes while sitting upright and leaning slightly forward. If bleeding persists beyond 20-30 minutes, is extremely heavy, or is accompanied by symptoms like dizziness, weakness, or rapid heart rate, immediate medical attention is necessary. The clinician should initiate first-line treatments prior to transfusion, reversal of anticoagulation, or withdrawal of anticoagulation/antiplatelet medications for patients using these medications, as recommended in the clinical practice guideline: nosebleed (epistaxis) executive summary 1.

Reversal of Anticoagulation

Emergency departments may need to reverse anticoagulation using specific reversal agents like vitamin K (for warfarin), protamine (for heparin), or newer agents like idarucizumab (for dabigatran) or andexanet alfa (for factor Xa inhibitors) in severe cases, as listed in Table 9 of the clinical practice guideline: nosebleed (epistaxis) 1. The clinician should use resorbable packing for patients with a suspected bleeding disorder or for patients who are using anticoagulant or antiplatelet medications, and educate the patient who undergoes nasal packing about the type of packing placed, timing of and plan for removal of packing, postprocedure care, and any signs or symptoms that would warrant prompt reassessment.

Key Considerations

• Patients on anticoagulants are more likely to present with recurrent epistaxis, have a large volume of blood loss, and require blood transfusion for treatment, as noted in the clinical practice guideline: nosebleed (epistaxis) 1.
• The clinician should document factors that increase the frequency or severity of bleeding for any patient with a nosebleed, including personal or family history of bleeding disorders, use of anticoagulant or antiplatelet medications, or intranasal drug use, as recommended in the clinical practice guideline: nosebleed (epistaxis) executive summary 1.
• The clinician should evaluate, or refer to a clinician who can evaluate, candidacy for surgical arterial ligation or endovascular embolization for patients with persistent or recurrent bleeding not controlled by packing or nasal cauterization, as noted in the clinical practice guideline: nosebleed (epistaxis) 1.

From the FDA Drug Label

Fatal or nonfatal hemorrhage from any tissue or organ. This is a consequence of the anticoagulant effect. Hemorrhage and necrosis have in some cases been reported to result in death or permanent disability.

Yes, epistaxis (nosebleed) can be fatal in patients on anticoagulants (blood thinners) due to the risk of hemorrhage from any tissue or organ, including the nose.

• The risk of fatal hemorrhage is a known consequence of anticoagulant therapy with warfarin sodium 2.
• Hemorrhagic complications, including those from epistaxis, can present with various signs and symptoms, and the possibility of hemorrhage should be considered in evaluating the condition of any anticoagulated patient 2.

From the Research

Epistaxis and Blood Thinners

• Epistaxis, or nosebleed, can be a potentially life-threatening condition, especially in patients taking anticoagulants (blood thinners) 3, 4, 5, 6, 7.
• The use of anticoagulants, such as warfarin, can increase the risk of bleeding complications, including epistaxis 3, 4.
• Studies have shown that patients on warfarin can safely continue their medication if their International Normalized Ratio (INR) is within the therapeutic range, without an increased risk of bleeding complications or failure of epistaxis control 3.
• Direct oral anticoagulants (DOACs), such as rivaroxaban and dabigatran, have also been shown to be safe in patients with epistaxis, with no significant differences in management or outcomes compared to warfarin 4.
• However, a systematic review found a lack of evidence regarding the management of antithrombotic therapy during epistaxis, highlighting the need for further research 5.

Fatalities Due to Epistaxis

• While epistaxis can be a life-threatening condition, fatalities due to nosebleed are relatively rare 7.
• Severe or refractory bleeding can occur, especially in patients with underlying bleeding disorders or neoplasia, and may require aggressive treatment, including medications, packing materials, and radiologic or surgical interventions 6, 7.
• The management of epistaxis in patients on anticoagulants requires careful consideration of the risks and benefits of continuing or discontinuing anticoagulant therapy, as well as the use of appropriate treatments to control bleeding 3, 4, 5.

Treatment and Management

• Treatment of epistaxis typically involves compressive therapy, nasal cautery, and topical therapy, with nasal packing and surgical interventions reserved for more severe or refractory cases 6, 7.
• Patients on anticoagulants may require closer monitoring and more aggressive treatment to control bleeding, and may benefit from consultation with a hematologist or cardiologist 5.