Management of Recurrent Epistaxis in Patients with End-Stage Renal Disease on Anticoagulants
For patients with ESRD on anticoagulants experiencing recurrent epistaxis, first-line treatments such as nasal compression, vasoconstrictors, moisturizing agents, nasal cautery, and/or nasal packing should be attempted before considering reversal of anticoagulation or withdrawal of anticoagulant medications. 1
Initial Assessment and Management
Risk Stratification
- Determine severity of epistaxis:
- Non-life-threatening: Controlled with pressure, no hemodynamic instability
- Life-threatening: Significant blood loss (>250mL), hemodynamic instability, airway compromise
First-Line Interventions (for all patients)
- Apply direct pressure to the anterior nasal septum for 15 minutes
- Use topical vasoconstrictors (e.g., oxymetazoline)
- Apply moisturizing/lubricating agents to prevent mucosal drying
- Consider chemical or electrical cautery for identifiable bleeding points
- Use nasal packing if the above measures fail
Special Considerations for ESRD Patients
Anticoagulation Management
- Do not immediately reverse or withdraw anticoagulation unless bleeding is life-threatening 1
- Continue anticoagulation during first-line treatments to avoid increased thrombotic risk
- For patients on warfarin: Check INR and ensure it's within therapeutic range
- For patients on DOACs (e.g., apixaban): No dose adjustment is recommended for ESRD patients on dialysis 2
ESRD-Specific Considerations
- Control blood pressure aggressively as hypertension is common in ESRD
- Consider dialysis schedule in relation to bleeding episodes
- Monitor for uremic platelet dysfunction which may worsen bleeding tendency
- Assess for anemia which is common in ESRD patients
Management Algorithm for Persistent/Recurrent Epistaxis
If First-Line Treatments Fail:
For non-life-threatening bleeding:
- Continue anticoagulation
- Consider specialized nasal packing techniques
- Consider bivalve septal teflon splint (BSTS) for recurrent mild epistaxis 3
- Schedule follow-up within 24-48 hours
For life-threatening bleeding:
- Consider temporary interruption of anticoagulation
- For VKA (warfarin): Consider fresh frozen plasma or 4-factor PCC 1
- For heparin: Consider protamine sulfate 1
- For DOACs: Consider 4-factor PCC or specific antidotes (e.g., idarucizumab for dabigatran) 1
- Consider surgical intervention or embolization if bleeding persists
Advanced Interventions:
- Endoscopic sphenopalatine artery ligation
- Arterial embolization (recurrence rate <10%) 1
- Surgical artery ligation (recurrence rate <10%) 1
Long-Term Management
Prevention Strategies
- Regular nasal moisturization with saline sprays or petroleum-based ointments
- Humidification of home environment
- Avoidance of digital trauma (nose picking)
- Blood pressure control
Follow-up and Monitoring
- Document outcomes within 30 days to assess treatment efficacy 1
- Regular reassessment of anticoagulation necessity and dosing
- Consider reduced-dose anticoagulation if appropriate for the underlying condition 1
- Monitor for recurrent bleeding (up to 41.5% of patients may experience recurrence) 4
Pitfalls and Caveats
- Do not immediately reverse anticoagulation for non-life-threatening epistaxis as this increases thrombotic risk 1
- Do not assume all epistaxis in anticoagulated patients is solely due to anticoagulation - investigate other causes if bleeding persists
- Do not discontinue antiplatelet or anticoagulant therapy without consulting the prescribing physician
- Be aware that patients on vitamin K antagonists (VKA) have significantly higher risk of recurrent epistaxis (odds ratio of 11.6) 4
- Remember that patients on aspirin may require more aggressive interventions for recurrent bleeding 4
Long-term management of these patients requires balancing the risk of recurrent epistaxis against the risk of thrombotic events, with first-line treatments being the mainstay of management before considering any changes to anticoagulation therapy.