What is the management of epistaxis in a patient taking Eliquis (apixaban)?

Management of Epistaxis in Patients Taking Eliquis (Apixaban)

Patients taking Eliquis (apixaban) who experience epistaxis should sit with their head slightly forward, pinch the lower third (soft portion) of the nose continuously for 10-15 minutes, and seek medical attention if bleeding does not stop or if they become lightheaded. 1

First-Line Management

1. Initial Approach:

   • Have the patient sit with head tilted slightly forward (to prevent blood from entering airway or stomach)
   • Apply continuous pressure by pinching the lower third (soft portion) of the nose for 10-15 minutes 1
   • Instruct patient to breathe through mouth and spit out any blood
   • This approach alone resolves the vast majority of cases, including 20% of cases managed in emergency departments 1

2. Additional First-Line Measures:

   • Consider application of topical vasoconstrictors (e.g., oxymetazoline or phenylephrine nasal sprays) 2
   • Anterior rhinoscopy to identify bleeding site after removing blood clots 2
   • For persistent bleeding, chemical or electrical cautery may be attempted for accessible anterior bleeding sites 1

Special Considerations for Patients on Apixaban

• Medical Attention Threshold: Patients on anticoagulants like Eliquis should seek medical care if bleeding doesn't stop promptly, even if the bleeding appears controlled 1

• Medication Management:

  • In the absence of life-threatening bleeding, do NOT discontinue Eliquis before attempting first-line treatments 1
  • First-line treatments should be tried before considering medication changes, reversal agents, or blood products 1

• When to Consider Advanced Interventions:

  • For severe, uncontrolled bleeding despite proper first-line measures
  • If patient shows signs of hemodynamic instability
  • For recurrent episodes despite adequate local measures

Nasal Packing and Advanced Interventions

• If first-line measures fail, anterior nasal packing may be necessary
• Patients on Eliquis are more likely to experience recurrent epistaxis compared to those on traditional anticoagulants or non-anticoagulated patients 3
• Consider topical tranexamic acid application as an alternative to nasal packing, as it can reduce bleeding time and decrease rebleeding episodes 4

When to Consider Reversal of Anticoagulation

• Reversal of anticoagulation should be considered only in life-threatening bleeding situations 1
• Andexanet alfa is the specific reversal agent for factor Xa inhibitors like apixaban, though availability may be limited
• Consultation with hematology is recommended before reversal due to increased thrombotic risk associated with withholding anticoagulation 1

Follow-up and Prevention

• Preventive Measures:

  • Regular nasal moisturization with saline gel or spray 1-3 times daily 2
  • Humidification at bedside, especially during sleep 2
  • Avoiding digital trauma (nose picking) and environmental irritants 2
  • Application of moisturizing agents to the anterior nasal septum 2

• Follow-up Care:

  • Document outcomes for at least 30 days to assess effectiveness of interventions 1
  • Evaluate for recurrent bleeding, which may indicate need for additional interventions or underlying conditions

When to Seek Emergency Care

• Bleeding that doesn't stop after 15 minutes of continuous pressure 1
• Lightheadedness or signs of significant blood loss 1
• Signs of brain injury, nasal deformity, or facial fracture if epistaxis is due to trauma 1
• Severe bleeding requiring blood transfusion

Remember that patients on anticoagulants like Eliquis are at higher risk for prolonged bleeding and recurrence, requiring closer monitoring and potentially more aggressive management strategies.