Diamox and Nosebleeds
Acetazolamide (Diamox) is not a recognized cause of epistaxis (nosebleeds) based on current clinical guidelines and evidence. The American Academy of Otolaryngology-Head and Neck Surgery's comprehensive 2020 epistaxis guideline does not list carbonic anhydrase inhibitors like acetazolamide among medications that increase nosebleed risk 1.
Medications That Actually Cause Nosebleeds
The established medication-related causes of epistaxis include:
- Anticoagulants and antiplatelet agents (warfarin, rivaroxaban, dabigatran, aspirin, clopidogrel) substantially increase epistaxis risk and severity 1, 2
- Intranasal corticosteroids dramatically increase nosebleed risk with a relative risk of 2.74 (range 1.88-4.00) compared to placebo 1
- Selective serotonin reuptake inhibitors (SSRIs) have been documented to cause nosebleeds 2
- Intranasal vasoconstrictors (oxymetazoline/Afrin) can cause nasal dryness and bleeding with repeated use 1
Why Acetazolamide Is Not Associated with Epistaxis
Acetazolamide's known adverse effects involve different organ systems, not the nasal mucosa:
- Gastrointestinal bleeding can occur with acetazolamide toxicity, manifesting as hemorrhagic gastritis rather than epistaxis 3
- Metabolic effects include diuresis, electrolyte disturbances, and metabolic acidosis 4
- Renal complications such as hemorrhagic anuria have been reported 5
- Hematologic effects like thrombocytopenia occur only in severe toxicity cases 3
Clinical Caveat
If a patient on acetazolamide develops nosebleeds, look for alternative explanations rather than attributing it to the medication 1, 6:
- Concurrent use of anticoagulants or antiplatelet drugs 1
- Intranasal corticosteroid use 1
- Local trauma or environmental factors (dry air, digital manipulation) 6
- Underlying bleeding disorders 1
- Hypertension (though not causally proven, it's associated with more severe epistaxis) 1, 6
The absence of acetazolamide from comprehensive epistaxis guidelines and drug-induced bleeding literature strongly indicates it is not a clinically relevant cause of nosebleeds 1, 2.