From the Guidelines
For severe anterior epistaxis, oxymetazoline (0.05%) or phenylephrine (0.25-1%) nasal sprays are recommended as first-line treatments. These vasoconstrictors should be applied by spraying directly into the bleeding nostril, followed by pinching the soft part of the nose for 10-15 minutes to apply pressure. They work by constricting blood vessels to reduce bleeding and can be effective for immediate management, with studies reporting that 65% to 75% of patients have resolution of nasal bleeding with oxymetazoline 1.
Key Considerations
- The use of these agents may be associated with an increased risk of cardiac or other systemic complications, particularly in patients with hypertension, cardiovascular disease, or nasal disease 1.
- For recurrent or persistent nosebleeds, prescription options include tranexamic acid nasal spray, which inhibits clot breakdown, or topical antibiotic ointments containing bacitracin or mupirocin if the bleeding is associated with nasal crusting or irritation.
- Patients should limit use of oxymetazoline or phenylephrine to 3-5 days to avoid rebound congestion.
- If bleeding continues despite these measures, seeking medical attention is necessary as packing, cauterization, or other interventional procedures may be required, and nasal endoscopy may be indicated to localize the bleeding site and evaluate for underlying nasal pathology 1.
Additional Treatment Options
- Tranexamic acid (TXA) is an inexpensive antifibrinolytic agent that has been used to control acute nosebleeds, with studies showing higher rates of acute bleeding control and earlier discharge with topical TXA compared to anterior nasal packing 1.
- Topical application of TXA may be effective for patients taking antiplatelet drugs, such as aspirin and/or clopidogrel, who are at increased risk of bleeding 1.
From the FDA Drug Label
Directions: Adults and children 6 to under 12 years of age (with adult supervision): 2 or 3 sprays in each nostrill not more often than every 10 to 12 hours. Do not exceed 2 doses in any 24-hour period. The oxymetazoline nasal spray is recommended for severe anterior epistaxis, with a dosage of 2 or 3 sprays in each nostril, not more often than every 10 to 12 hours 2.
From the Research
Nasal Sprays for Severe Anterior Epistaxis
- Oxymetazoline nasal spray is a recommended treatment for severe anterior epistaxis, as it can stop 65-75% of nosebleeds in the emergency department 3.
- Oxymetazoline 0.05% nasal spray can be used to address rebleeding after discharge from treatment 4.
- A study found that 65% of patients with epistaxis were successfully managed with oxymetazoline as their sole therapy, and an additional 18% were managed successfully with silver nitrate cautery in combination with oxymetazoline 5.
- Another study compared the efficacy of oxymetazoline, tranexamic acid, and epinephrine-lidocaine combination in the treatment of epistaxis, and found that oxymetazoline achieved hemostasis in 71% of patients, making it a superior option for achieving rapid hemostasis and reducing recurrence in epistaxis 6.
Additional Treatment Options
- Topical agents, such as tranexamic acid, can also be used to promote hemostasis in patients with epistaxis 3.
- Electrocautery and chemical cauterization are other treatment options for epistaxis, but may have higher recurrence rates compared to oxymetazoline 3.
- Nasal packing can be applied with non-absorbable or absorbable materials, but may be associated with discomfort and complications 3, 7.
Recommendations
- Oxymetazoline nasal spray is a recommended first-line treatment for severe anterior epistaxis due to its high success rate and ease of use 3, 4, 5, 6.
- Other treatment options, such as topical agents and nasal packing, may be considered if oxymetazoline is not effective or if the patient has a history of recurrent epistaxis 3, 7.