What to do if experiencing epistaxis while taking Eliquis (apixaban)?

Management of Nosebleeds While Taking Eliquis (Apixaban)

Start with direct nasal compression and topical vasoconstrictors as first-line treatment—do not stop Eliquis or reverse anticoagulation unless bleeding is life-threatening, as the thrombotic risk from stopping anticoagulation far outweighs the benefit in most epistaxis cases. 1, 2

Immediate First-Line Treatment

• Sit upright with head tilted slightly forward (not backward) to prevent blood from entering the airway or stomach 1, 3

• Apply firm, continuous compression to the soft lower third of the nose for a full 10-15 minutes without checking if bleeding has stopped 1, 3

  • This is the single most important intervention and resolves the majority of cases, including 20% of emergency department epistaxis presentations 1
  • Breathe through the mouth and spit out any blood rather than swallowing it 1

• If bleeding persists after 15 minutes of compression, apply a topical vasoconstrictor (oxymetazoline or phenylephrine spray—2 sprays in the bleeding nostril), then continue compression for another 5 minutes 3, 4

  • This approach resolves 65-75% of epistaxis cases that don't stop with compression alone 3

Critical Medication Management Principles

• Do NOT stop taking Eliquis without consulting your prescribing physician 2

  • Stopping apixaban significantly increases your risk of stroke, which is far more dangerous than most nosebleeds 2

• Do NOT take additional doses of Eliquis while actively bleeding 4

• First-line local control measures should always be attempted before considering any anticoagulation reversal 1

  • The American Academy of Otolaryngology-Head and Neck Surgery explicitly recommends against withholding anticoagulation, reversing it, or administering blood products for non-life-threatening epistaxis 1

When to Seek Medical Attention

It is reasonable for patients on anticoagulants like Eliquis to seek professional medical care for epistaxis, unless bleeding has completely stopped 1

Seek immediate medical attention if: 1, 3, 2

• Bleeding does not stop after 15 minutes of continuous pressure
• You experience lightheadedness, dizziness, or weakness from blood loss
• Bleeding is severe (duration >30 minutes over a 24-hour period)
• You develop signs of hemodynamic instability such as rapid heartbeat or low blood pressure
• You experience frequent recurrent nosebleeds

Prevention of Recurrence

• Once bleeding stops, apply petroleum jelly or other lubricating agents to the nasal mucosa to prevent recurrence 3, 4

• Use saline nasal sprays regularly to keep nasal passages moist 3, 4

• Consider using a humidifier, especially in dry environments 5

Advanced Medical Management (If Basic Measures Fail)

If you require medical evaluation, your healthcare team may consider: 1, 4

• Nasal cauterization or packing by an ENT specialist
• Antifibrinolytic agents (such as tranexamic acid) or desmopressin to support hemostasis without reversing anticoagulation 1, 4, 6
• Reversal agents only for life-threatening bleeding: 4-factor prothrombin complex concentrate (PCC) is the reversal agent for apixaban, but this carries significant thrombotic risk and should be reserved for truly life-threatening situations 1

Common Pitfalls to Avoid

• Insufficient compression time: Many patients check too early—you must maintain pressure for the full 10-15 minutes 3, 5

• Tilting head backward: This causes blood to flow into the throat and stomach, potentially causing vomiting and does not help control bleeding 1

• Unnecessary anticoagulation reversal: This dramatically increases stroke risk and should only occur in life-threatening bleeding scenarios 1, 4

• Using ice/cryotherapy: There is insufficient evidence to support this practice 1, 4

Important Safety Information from FDA Label

The FDA medication guide for apixaban explicitly warns that: 2

• Nosebleeds that happen often are a recognized bleeding complication
• You should call your doctor or get medical help right away for unexpected bleeding or bleeding that lasts a long time
• You may bruise more easily and it may take longer than usual for bleeding to stop while on Eliquis
• Never stop taking apixaban without talking to the doctor who prescribed it, as this increases stroke risk