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

Management of Nosebleeds While Taking Eliquis (Apixaban)

Continue taking Eliquis and manage nosebleeds with local compression and topical measures first—do not stop the medication without consulting your prescribing physician, as the thrombotic risk from stopping typically outweighs the bleeding risk from minor nosebleeds. 1

Immediate Home Management

When a nosebleed occurs while on Eliquis, take these steps in order:

• Sit upright and lean your head slightly forward to prevent blood from entering your airway or stomach 1
• Apply firm, sustained compression to the lower third (soft part) of your nose for 5-15 minutes continuously without releasing pressure, which stops bleeding in 65-75% of cases 1
• Breathe through your mouth and spit out any blood rather than swallowing it 1
• After initial compression, spray oxymetazoline (Afrin) or phenylephrine nasal spray into the bleeding nostril and continue holding pressure for another 5 minutes 1

When to Seek Emergency Care Immediately

Go to the emergency department if you experience any of the following:

• Bleeding continues despite 15-30 minutes of proper compression 1
• Lightheadedness, weakness, or feeling faint 1
• Difficulty breathing due to blood in the airway 1
• Severe blood loss (filling a cup or more) 1
• Hemoglobin drop of 2 g/dL or greater 1

Critical Medication Management Principles

The decision to continue or stop Eliquis must be made carefully:

• Nosebleeds are a known side effect of Eliquis, and patients on anticoagulants are more likely to experience recurrent epistaxis 1, 2
• Continue Eliquis unless bleeding is life-threatening—the thrombotic risk from stopping typically outweighs the bleeding risk from minor epistaxis 1
• The physician who prescribed Eliquis must be involved in any decision about medication management 1
• For life-threatening bleeding only: Stop Eliquis immediately and consider reversal agents such as 4-factor prothrombin complex concentrate or andexanet alfa 1

Medical Treatment if Home Measures Fail

If you present to a medical facility for persistent bleeding:

• Anterior rhinoscopy will be performed to identify the bleeding site after clot removal 1
• Nasal cautery or moisturizing/lubricating agents may be applied to the bleeding site 1
• Resorbable packing materials are preferred if packing becomes necessary, as these are safer for patients on anticoagulants compared to traditional gauze 1
• Eliquis should be continued during medical treatment unless bleeding is life-threatening 1

Prevention of Future Nosebleeds

To reduce recurrence while continuing Eliquis:

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

Warning Signs Requiring Immediate Medical Attention

Beyond the nosebleed itself, contact your healthcare provider or go to the emergency department if you experience:

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

Important Caveats About Eliquis and Bleeding

Eliquis is a blood thinner that reduces blood clotting, which means you may bruise more easily and bleeding may take longer to stop 3. Other medications that increase bleeding risk when combined with Eliquis include aspirin, NSAIDs, warfarin, heparin, SSRIs/SNRIs, and other anticoagulants 3. Research confirms that while direct oral anticoagulants like apixaban have similar severe bleeding rates to warfarin in clinical trials, managing bleeding episodes can be more challenging because there is no routine coagulation test for monitoring and limited antidote availability 4. However, most nosebleeds on Eliquis are mild to moderate and can be controlled with local measures alone 2.