Management of Ongoing Epistaxis on Low-Dose Apixaban
Do not discontinue apixaban for recurrent epistaxis unless bleeding is life-threatening; instead, use first-line local hemostatic measures while continuing anticoagulation. 1
Immediate Management of Active Bleeding
Apply firm sustained compression to the lower third of the nose for at least 5-15 minutes with the patient seated and head tilted slightly forward, breathing through the mouth and spitting out blood rather than swallowing it. 1, 2
After compression:
- Clean the nasal cavity of clots and apply a topical vasoconstrictor (oxymetazoline or phenylephrine spray), which stops bleeding in 65-75% of cases. 2, 3
- If bleeding persists despite compression, use resorbable nasal packing specifically because the patient is on anticoagulation—this reduces rebleeding risk when packing is removed compared to non-resorbable materials. 1
Critical Principle: Continue Anticoagulation
In the absence of life-threatening bleeding (hemodynamic instability, airway compromise, signs of hypovolemia), initiate first-line treatments prior to reversal or withdrawal of apixaban. 1 This is a firm recommendation from the American Academy of Otolaryngology-Head and Neck Surgery because the thromboembolic risk of stopping anticoagulation typically outweighs the bleeding risk from epistaxis. 2
Life-threatening bleeding indicators requiring emergency evaluation include: 1
- Bleeding duration >30 minutes over 24 hours
- Signs of acute hypovolemia (tachycardia, syncope, orthostatic hypotension)
- Bilateral bleeding or bleeding from the mouth
- Hemodynamic instability
Preventive Measures for Recurrent Epistaxis
Apply petroleum jelly (Vaseline) to the anterior nasal septum 1-3 times daily, particularly before bedtime, to prevent recurrence. 2, 3, 4 This simple measure is highly effective and often underutilized. 3
Additional preventive strategies: 2, 3
- Use saline nasal sprays regularly to maintain mucosal moisture
- Consider bedside humidification during sleep
- Avoid digital trauma (nose picking) and vigorous nose blowing
When Initial Measures Fail
If bleeding recurs despite conservative management:
Perform nasal endoscopy to identify the specific bleeding site—this is essential for recurrent cases. 1, 2
Consider nasal cautery if a specific bleeding site is identified: 1, 2, 3
Apply topical vasoconstrictors along with moisturizing/lubricating agents as appropriate interventions for identified bleeding sites. 1
Specialist Referral Indications
Refer to otolaryngology if: 2
- Bleeding persists despite initial local measures
- Nasal endoscopy reveals difficult-to-control bleeding sites
- Surgical arterial ligation or endovascular embolization may be needed
Assess for hereditary hemorrhagic telangiectasia if the patient has recurrent bilateral nosebleeds or visible telangiectasias on nasal/oral mucosa. 2, 3
Common Pitfalls to Avoid
- Do not routinely discontinue apixaban for non-life-threatening epistaxis—the thromboembolic risk typically exceeds the bleeding risk. 1
- Do not underestimate simple nasal moisturization—this is highly effective for prevention but frequently overlooked. 3
- Do not use non-resorbable packing in anticoagulated patients when resorbable options are available, as removal of non-resorbable packing causes rebleeding. 1
- Apixaban has no readily available antidote for routine epistaxis management (andexanet alfa is reserved for life-threatening bleeding only). 1, 5
Documentation and Follow-Up
Document the outcome of intervention within 30 days to assess treatment effectiveness. 1, 2, 4 Educate the patient about preventive measures, proper home treatment technique (15 minutes of compression to lower third of nose), and indications to seek emergency care (bleeding not controlled after 15 minutes, signs of hemodynamic compromise). 2, 3, 4