What are the guidelines for holding apixaban (eliquis) in a patient with epistaxis and a known pulmonary embolism?

Management of Apixaban in Patients with Epistaxis and Pulmonary Embolism

For patients with epistaxis who have a known pulmonary embolism and are on apixaban, first-line treatments for epistaxis should be attempted before considering temporary interruption of anticoagulation, as the risk of thrombotic events from holding anticoagulation outweighs the risk of continued bleeding in most cases.

Initial Management of Epistaxis

When a patient on apixaban for pulmonary embolism presents with epistaxis, follow this approach:

First-Line Interventions (Without Holding Apixaban)

1. Direct pressure: Apply firm pressure to the anterior portion of the nose for at least 15 minutes
2. Vasoconstrictors: Use topical agents like oxymetazoline or phenylephrine
3. Chemical cautery: Silver nitrate application for localized bleeding points
4. Nasal packing: Consider anterior packing if bleeding persists

These first-line interventions should be attempted before considering any interruption of anticoagulation therapy 1. The Clinical Practice Guideline for Nosebleed recommends against immediately withholding anticoagulants prior to attempting these standard interventions.

When to Consider Holding Apixaban

Only consider holding apixaban in the following circumstances:

• Life-threatening epistaxis that is unresponsive to first-line interventions
• Hemodynamic instability despite adequate local control measures
• Need for surgical intervention where bleeding risk is high

If temporary interruption is necessary:

• For procedures with moderate/high bleeding risk: Discontinue apixaban at least 48 hours prior
• For procedures with low bleeding risk: Discontinue apixaban at least 24 hours prior 2

Risk Assessment

When deciding whether to hold apixaban, carefully weigh:

1. Thrombotic risk: Patients with recent PE (within 3 months) are at high risk for recurrent events if anticoagulation is interrupted
2. Bleeding severity: Most epistaxis can be managed without interrupting anticoagulation
3. Time since PE diagnosis: Risk of recurrence decreases with time from initial event

Duration of Interruption and Resumption

If interruption is absolutely necessary:

• Keep the interruption as brief as possible
• Resume apixaban as soon as adequate hemostasis is achieved
• Consider bridging therapy only in patients at very high thrombotic risk

Special Considerations

1. Recent PE diagnosis: If PE was diagnosed within the last 3 months, the risk of recurrence is highest, and interruption should be avoided if at all possible 1

2. Extended anticoagulation: For patients on indefinite anticoagulation for unprovoked PE, even brief interruptions increase thrombotic risk 1

3. Dose considerations:

   • For acute PE treatment: Apixaban is dosed at 10 mg twice daily for 7 days, followed by 5 mg twice daily 3
   • After 6 months: Consider reduced dose of 2.5 mg twice daily for extended prophylaxis 1

Important Cautions

• Premature discontinuation warning: The FDA label for apixaban carries a boxed warning about increased thrombotic risk with premature discontinuation 2

• Reversal strategies: Avoid using reversal agents, blood products, or clotting factors for non-life-threatening epistaxis 1

• Real-world evidence: Studies show apixaban has lower bleeding risk compared to warfarin while maintaining efficacy against recurrent VTE 4, making brief interruptions potentially more risky than continued therapy with local control measures

Follow-up Recommendations

After epistaxis resolves:

• Reassess bleeding risk factors
• Consider ENT referral for patients with recurrent epistaxis
• Evaluate for dose adjustment only if clinically indicated
• Regular monitoring of renal function, hepatic function, and bleeding risk for patients on extended anticoagulation 1, 3