How to manage a nosebleed in a patient with atrial fibrillation (AFib) on 2.5 mg apixaban (Eliquis) twice daily (BID)?

Management of Nosebleed in AFib Patient on Apixaban 2.5 mg BID

For a nosebleed in a patient on apixaban 2.5 mg BID, initiate firm sustained compression to the anterior nasal septum for 10-15 minutes with the head tilted forward, use resorbable nasal packing if compression fails, and delay the next dose of apixaban for 1 dose or 1 day—do NOT reverse anticoagulation or administer blood products unless the bleeding is life-threatening. 1

Initial Assessment and Immediate Management

First-Line Treatment

• Apply firm sustained compression to the soft cartilaginous part of the nose (nasal alae and anterior septal area) for a full 10-15 minutes without releasing pressure 1, 2
• Position the patient sitting upright with head tilted forward to prevent blood aspiration into the oropharynx and airway 1, 2
• This mechanical compression alone stops 90-95% of anterior nosebleeds 2

Assess Bleeding Severity

Determine if this requires prompt management by evaluating: 1

• Active bleeding status and hemodynamic stability
• Airway compromise risk from bleeding into oropharynx
• Time of last apixaban dose (critical for management decisions)
• Hemoglobin, hematocrit, platelet count, and renal function 1

Anticoagulation Management Strategy

For Minor Epistaxis (Most Common Scenario)

The European Society of Cardiology guidelines specifically classify this as minor bleeding requiring supportive measures only: 1

• Delay apixaban for 1 dose or 1 day (do not give the next scheduled dose) 1
• Improved hemostasis is expected within 12-24 hours given apixaban's short half-life of approximately 12 hours 1
• Do NOT administer reversal agents, blood products, or prothrombin complex concentrates for minor bleeding 1

Critical Caveat on Anticoagulation Reversal

The American Academy of Otolaryngology strongly recommends AGAINST withholding anticoagulants, administering reversal agents, clotting factors, or blood products prior to attempting first-line interventions unless bleeding is life-threatening. 1 This approach:

• Controls nosebleeds without increasing thrombotic risk from withholding medications 1
• Reduces blood product exposure and associated risks 1
• Decreases unnecessary costs 1

Nasal Packing Considerations

When Compression Fails

If firm compression for 10-15 minutes does not control bleeding: 1

• Use resorbable packing materials specifically for patients on anticoagulants 1
• Resorbable options include nasal tampon (Nasopore), hemostatic gauzes (Surgicel), thrombin matrix (Floseal), gelatin sponge (Spongostan), or fibrin glue 3
• These newer hemostatic materials are more effective with fewer complications than traditional packing 3

Patient Education After Packing

Document and educate the patient about: 1

• Type of packing placed
• Timing and plan for removal (if not resorbable)
• Post-procedure care instructions
• Signs/symptoms requiring prompt reassessment

When to Escalate Care

Indications for Specialist Referral

Refer to otolaryngology for: 1

• Persistent or recurrent bleeding despite packing or cauterization
• Evaluation for surgical arterial ligation or endovascular embolization
• Nasal endoscopy to examine the nasal cavity and identify bleeding source
• Recurrent bilateral nosebleeds (assess for hereditary hemorrhagic telangiectasia)

Life-Threatening Bleeding Protocol

Only for severe or life-threatening epistaxis with hemodynamic instability: 1

• Consider 4-factor prothrombin complex concentrates (PCC) if specific antidote unavailable 1
• Andexanet alpha (factor Xa inhibitor reversal agent) may be considered for apixaban 1
• Fluid replacement and blood transfusion as needed 1
• Oral charcoal if apixaban was ingested within 2-4 hours 1

Resuming Anticoagulation

Resume apixaban as soon as adequate hemostasis is established (typically after 12-24 hours for minor epistaxis). 1 The stroke risk from prolonged anticoagulation interruption outweighs the bleeding risk in most cases, as this patient is on the reduced 2.5 mg BID dose (indicating age ≥80 years, weight ≤60 kg, or creatinine ≥1.5 mg/dL—all factors increasing stroke risk). 4

Common Pitfalls to Avoid

• Do not tilt the head backward—this increases aspiration risk and does not improve hemostasis 2
• Do not reflexively reverse anticoagulation—first-line local measures are effective in >90% of cases 1, 2
• Do not apply compression to the nasal bridge—the bleeding source is in the anterior septum, not the nasal bones 2
• Do not minimize OAC interruptions unnecessarily—prolonged interruption increases stroke risk significantly 1