What to do for a nose bleed after increasing Eliquis (apixaban) dose?

From the Guidelines

For a nosebleed after increasing Eliquis (apixaban) dose, contact your healthcare provider immediately as this could indicate excessive anticoagulation. While waiting for medical advice, sit upright, lean slightly forward, and pinch the soft part of your nose firmly for 10-15 minutes without releasing, as recommended by the clinical practice guideline for nosebleed management 1. Apply an ice pack to the bridge of your nose. Do not tilt your head back, lie down, or insert anything into your nostril. Avoid blowing your nose for several hours after the bleeding stops.

Key Considerations

• Nosebleeds are a concerning side effect of Eliquis because it's an anticoagulant that prevents blood clotting, and increasing the dose can amplify this effect 1.
• Your doctor may need to adjust your medication dosage or perform tests to check your bleeding risk, considering the use of anticoagulant or antiplatelet medications as a factor that increases the frequency or severity of bleeding 1.
• Never stop taking Eliquis without medical guidance, as this could increase your risk of stroke or blood clots.
• Stay hydrated and consider using a humidifier to prevent nasal dryness that could trigger additional bleeding, as humidification and intranasal emollients are part of the initial treatment options for nosebleeds 1.

Management Options

• The clinician should treat patients with an identified site of bleeding with an appropriate intervention, which may include one or more of the following: topical vasoconstrictors, nasal cautery, and moisturizing or lubricating agents 1.
• The clinician should use resorbable packing for patients with a suspected bleeding disorder or for patients who are using anticoagulation or antiplatelet medications, such as Eliquis 1.
• In the absence of life-threatening bleeding, the clinician should initiate first-line treatments prior to transfusion, reversal of anticoagulation, or withdrawal of anticoagulation/antiplatelet medications for patients using these medications 1.

From the FDA Drug Label

Apixaban can cause bleeding which can be serious and rarely may lead to death. This is because apixaban is a blood thinner medicine that reduces blood clotting You may have a higher risk of bleeding if you take apixaban tablets and take other medicines that increase your risk of bleeding, including: Call your doctor or get medical help right away if you have any of these signs or symptoms of bleeding when taking apixaban tablets: unexpected bleeding, or bleeding that lasts a long time, such as: unusual bleeding from the gums nosebleeds that happen often menstrual bleeding or vaginal bleeding that is heavier than normal bleeding that is severe or you cannot control

If you experience a nose bleed after increasing your Eliquis (apixaban) dose, seek medical attention immediately. Nosebleeds that happen often are a sign of bleeding, and apixaban can cause bleeding which can be serious. Inform your doctor about the nose bleed, and they will assess the situation and provide guidance on how to manage it. Do not stop taking apixaban tablets without talking to your doctor. 2

From the Research

Management of Nose Bleed after Increasing Eliquis (Apixaban) Dose

• The management of epistaxis, particularly in patients on anticoagulant therapy like Eliquis (apixaban), is crucial to prevent severe complications 3.
• Studies suggest that tranexamic acid, an antifibrinolytic agent, can be effective in reducing the risk of re-bleeding in patients with epistaxis 4, 5.
• Topical application of tranexamic acid has been shown to be effective in stopping bleeding in patients with epistaxis, with a significant reduction in re-bleeding rates compared to anterior nasal packing 5.
• Nasal saline gel can also be an effective alternative to invasive measures in treating recurrent epistaxis in anticoagulated patients, with a high success rate in stopping bleeding 6.

Treatment Options

• Compressive therapy is the first step in controlling anterior epistaxis, and can be supplemented with oxymetazoline nasal spray or application of cotton soaked in oxymetazoline or epinephrine 1:1,000 7.
• Directive nasal cautery using silver nitrate can be used to control localized continued bleeding or prominent vessels that are the suspected bleeding source 7.
• Topical therapy and nasal packing can be used if other methods are unsuccessful, although posterior nasal packing is often associated with pain and a risk of aspiration if it is dislodged 7.

Considerations for Anticoagulated Patients

• Anticoagulant and antiplatelet drugs, including Eliquis (apixaban), can increase the risk of epistaxis, and patients on these medications should be closely monitored for signs of bleeding 3.
• The use of tranexamic acid or nasal saline gel may be beneficial in reducing the risk of re-bleeding in anticoagulated patients with epistaxis 4, 6.