What to do for a patient with recurrent epistaxis (nosebleeds) twice daily while taking Eliquis (apixaban) 5mg twice daily?

Management of Recurrent Epistaxis in a Patient Taking Apixaban

For a patient with recurrent epistaxis (twice daily) while on Eliquis (apixaban) 5mg twice daily, first-line treatment should include nasal compression, topical vasoconstrictors, and nasal moisturization while continuing anticoagulation therapy unless bleeding is life-threatening.

Initial Management

• Apply firm sustained compression to the lower third of the nose for 5-15 minutes with the patient seated and head tilted slightly forward 1, 2
• Have the patient breathe through the mouth and spit out blood rather than swallowing it 2
• After compression, clean the nasal cavity of clots and apply a topical vasoconstrictor (oxymetazoline or phenylephrine) 2
• For this patient with recurrent epistaxis, use resorbable packing materials if packing becomes necessary due to their anticoagulant use 1, 2

Addressing Recurrent Epistaxis

• Document factors that increase bleeding frequency/severity, particularly the use of apixaban 1
• In the absence of life-threatening bleeding, continue apixaban and initiate first-line treatments rather than reversing or withdrawing anticoagulation 1, 3
• Apply moisturizing or lubricating agents (petroleum jelly) to the nasal mucosa to prevent recurrence 2
• Recommend regular use of saline nasal sprays to keep the nasal mucosa moist 2
• Consider using a humidifier, especially in dry environments 4

Advanced Management for Recurrent Cases

• Perform nasal endoscopy to identify the bleeding site and guide further management in this patient with recurrent bleeding 1
• Consider nasal cautery if a specific bleeding site is identified, ensuring proper anesthesia and restricting cautery only to the active bleeding site 1
• Educate the patient about preventive measures, home treatment, and indications to seek additional medical care 1

When to Consider Specialist Referral

• If bleeding persists despite initial measures, refer to an otolaryngologist 2
• Consider evaluation for surgical arterial ligation or endovascular embolization if bleeding is not controlled by packing or nasal cauterization 1, 2
• Assess for possible hereditary hemorrhagic telangiectasia if the patient has recurrent bilateral nosebleeds 1

Important Considerations for Patients on Apixaban

• Apixaban increases the risk of bleeding and can cause serious, potentially fatal bleeding 3
• Do not discontinue apixaban without medical supervision as premature discontinuation increases thrombotic risk 3
• The anticoagulant effect of apixaban persists for at least 24 hours after the last dose 3
• Concomitant use of other drugs affecting hemostasis (aspirin, NSAIDs, other anticoagulants) further increases bleeding risk 3

Follow-up Recommendations

• Document the outcome of intervention within 30 days 1
• If nasal packing was used, educate the patient about care and signs/symptoms that would warrant reassessment 1
• Consider reducing apixaban dose by 50% if the patient is also taking combined P-gp and strong CYP3A4 inhibitors 3