What to do for a patient on Rivaroxaban (Xarelto) experiencing epistaxis (nose bleeds)?

Management of Rivaroxaban-Associated Epistaxis

For patients on rivaroxaban experiencing epistaxis, continue the anticoagulant and initiate local bleeding control measures first—do not stop rivaroxaban or reverse anticoagulation unless the bleeding is life-threatening or uncontrollable with local measures. 1

Initial Assessment and Classification

Determine bleeding severity immediately:

• Non-major epistaxis (most cases): No hemodynamic instability, hemoglobin drop <2 g/dL, no transfusion needed, not at a critical site 1
• Major epistaxis: Hemodynamic instability, hemoglobin decrease ≥2 g/dL, administration of ≥2 units RBCs, or bleeding at a critical site 1

Management Algorithm for Non-Major Epistaxis

Continue rivaroxaban and apply local measures 1:

1. Firm sustained compression to the lower third of the nose for 5-15 minutes with patient seated and head tilted slightly forward 1

2. After compression, clean nasal cavity of clots and apply topical vasoconstrictors (oxymetazoline or phenylephrine)—this stops bleeding in 65-75% of cases 2

3. If bleeding persists, perform anterior rhinoscopy to identify the bleeding site after clot removal 1

4. Treat identified bleeding site with nasal cautery (after anesthetizing the site) or moisturizing/lubricating agents 1

5. If still bleeding, use resorbable nasal packing—specifically recommended for patients on anticoagulants 1

Critical point: In the absence of life-threatening bleeding, initiate these first-line treatments prior to transfusion, reversal of anticoagulation, or withdrawal of rivaroxaban 1

Management Algorithm for Major/Life-Threatening Epistaxis

Stop rivaroxaban immediately 1:

1. Provide local therapy/manual compression 1

2. Provide supportive care and volume resuscitation 1

3. Consider reversal agents if bleeding is at a critical site or life-threatening 1:

   • First choice: Andexanet alfa (if available) 1
     • Low dose: 400 mg IV bolus followed by 4 mg/min infusion for 120 minutes if last rivaroxaban dose ≤10 mg taken <8 hours prior 1
     • High dose: 800 mg IV bolus followed by 8 mg/min infusion for 120 minutes if last rivaroxaban dose >10 mg taken <8 hours prior 1
   • Alternative: Four-factor prothrombin complex concentrate (4F-PCC) if andexanet alfa unavailable 1

4. Activated charcoal if rivaroxaban taken within previous 2 hours 1, 3

5. Assess for surgical/procedural management of bleeding site if above measures fail 1

Pharmacokinetic Considerations

Rivaroxaban half-life varies by renal function 1:

• Normal renal function (CrCl ≥80 mL/min): 6-9 hours 1
• Moderate impairment (CrCl 30-49 mL/min): 9 hours 1
• Severe impairment (CrCl 15-29 mL/min): 13 hours (off dialysis) 1

This means in patients with normal renal function, rivaroxaban effect will diminish significantly within 12-24 hours of holding the medication 1, 4

When to Restart Rivaroxaban After Major Bleeding

Once bleeding is controlled and patient is stable, assess the following 1:

Delay restart if any of these apply 1:

• Bleed occurred at a critical site
• Patient at high risk of rebleeding or death/disability with rebleeding
• Source of bleed not yet identified
• Surgical/invasive procedures planned

Restart timing when appropriate 1, 5:

• Low bleeding risk: Resume 24 hours after hemostasis achieved 1, 5
• High bleeding risk: Resume 48-72 hours after hemostasis achieved 1, 5

Common Pitfalls to Avoid

• Do not routinely stop rivaroxaban for minor epistaxis—this increases thrombotic risk without improving outcomes 1
• Do not use reversal agents for non-major bleeding—local control is sufficient and reversal carries thrombotic risks 1
• Do not perform bilateral simultaneous septal cautery—increases risk of septal perforation 2
• Rivaroxaban is not dialyzable due to high plasma protein binding—dialysis will not help in overdose situations 3
• Do not underestimate simple nasal moisturization—petroleum jelly and saline sprays prevent recurrence effectively 2

Patient Education and Follow-Up

Educate patients on 1:

• Avoid straining, lifting >10 pounds, bending over, and exercising during active bleeding 1
• Sleep with head slightly elevated 1
• Use acetaminophen for pain (not aspirin or ibuprofen) 1
• Apply nasal saline sprays regularly to keep mucosa moist 1, 2
• Seek immediate care if bleeding persists >15 minutes despite compression, or if fever >101°F, vision changes, or facial swelling develop 1

Document outcome within 30 days 1, 2