What should I do if I experience nose bleeds while taking Eliquis (apixaban)?

Management of Nosebleeds on Eliquis (Apixaban)

Do not stop taking Eliquis for nosebleeds unless the bleeding is life-threatening—instead, use local control measures first, as stopping the medication significantly increases your risk of stroke or blood clots. 1, 2

Immediate Home Management

Apply firm, sustained compression to the lower third (soft part) of your nose for a full 5-15 minutes without releasing pressure. 1, 2

• Sit upright and lean your head slightly forward to prevent blood from entering your airway or stomach 2
• Breathe through your mouth and spit out any blood rather than swallowing it 2
• After compression, spray oxymetazoline (Afrin) or phenylephrine nasal spray (2 sprays in the bleeding nostril) and continue holding pressure for another 5 minutes 1, 2
• This approach stops bleeding in 65-75% of cases 2

When to Seek Emergency Care

Go to the emergency department immediately if: 2

• Bleeding continues despite 15-30 minutes of proper compression 2
• You experience lightheadedness, weakness, or feel faint 2
• You have difficulty breathing due to blood in the airway 2
• You have severe blood loss (filling a cup or more) 2
• You develop hemodynamic instability or a hemoglobin drop ≥2 g/dL 2

What NOT to Do

Critical pitfall: Do not routinely stop Eliquis for minor nosebleeds, as this increases thrombotic risk (stroke, blood clots) without improving outcomes. 2

• The American Academy of Otolaryngology-Head and Neck Surgery explicitly recommends continuing anticoagulation and using first-line local treatments before considering medication withdrawal, except in life-threatening bleeding 1
• Reversal agents should not be used for non-major bleeding, as local control is sufficient and reversal carries significant thrombotic risks 2

Prevention of Future Episodes

To reduce recurrent nosebleeds while continuing Eliquis: 2

• Apply petroleum jelly (Vaseline) or saline gel inside the nostrils 1-3 times daily 2
• Use saline nasal spray regularly to keep nasal mucosa moist 2
• Run a humidifier at your bedside, especially in dry environments 2
• Avoid nose picking, forceful nose blowing, and intranasal cocaine or excessive nasal decongestant spray use 2

Activity Restrictions During Active Bleeding

While experiencing nosebleeds: 1

• Avoid straining, lifting over 10 pounds, bending over, and exercising 1
• Sleep with your head slightly elevated 1
• Avoid over-the-counter pain medications that increase bleeding, including aspirin and ibuprofen—use acetaminophen (Tylenol) instead 1
• If you need to sneeze, sneeze with your mouth open 1

Medical Treatment if Home Measures Fail

If bleeding persists despite compression and topical vasoconstrictors, medical providers should: 1

• Perform anterior rhinoscopy to identify the bleeding site after clot removal 1
• Use nasal cautery (after anesthetizing the site) or apply moisturizing/lubricating agents to the identified bleeding site 1
• Use resorbable packing materials (not traditional gauze) if packing becomes necessary, as these are safer for patients on anticoagulants 1
• Continue Eliquis unless bleeding is life-threatening, as the guideline states "in the absence of life-threatening bleeding, the clinician should initiate first-line treatments prior to transfusion, reversal of anticoagulation, or withdrawal of anticoagulation/antiplatelet medications" 1

Life-Threatening Bleeding Protocol

Only for major/life-threatening epistaxis (hemodynamic instability, hemoglobin drop ≥2 g/dL, bleeding at critical site): 2

• Stop Eliquis immediately and provide local therapy/manual compression 2
• Provide supportive care and volume resuscitation 2
• Consider reversal agents such as 4-factor prothrombin complex concentrate (PCC) or andexanet alfa 1, 2
• Activated charcoal can be used if Eliquis was taken within the previous 2 hours 2

Coordination with Your Prescribing Physician

The physician who prescribed Eliquis must be involved in any decision about medication management. 2

• Nosebleeds are a known side effect of Eliquis, and patients taking anticoagulants are more likely to present with recurrent epistaxis 1
• However, the thrombotic risk from stopping Eliquis (stroke, blood clots) typically outweighs the bleeding risk from minor epistaxis 1, 2
• Your cardiologist or prescribing physician should determine when it is safe to restart Eliquis after major bleeding (typically 24 hours for low bleeding risk, 48-72 hours for high bleeding risk) 2

Warning Signs Requiring Immediate Medical Attention

Contact your healthcare provider or go to the emergency department if you experience: 1

• Fever over 101°F 1
• Vision changes 1
• Shortness of breath or labored breathing 1
• Swelling of the face 1
• Diffuse skin rash 1
• Increasing pain 1