What is the management for a nose bleed in a patient on Eliquis (apixaban) and Plavix (clopidogrel)?

Management of Nosebleed in Patients on Eliquis and Plavix

Continue both Eliquis and Plavix while applying aggressive local measures, and only discontinue these medications if bleeding is life-threatening with hemodynamic instability. 1, 2, 3

Immediate Home Management

Apply firm, sustained compression to the soft lower third of the nose for a full 15 minutes without releasing pressure to check if bleeding has stopped. 4, 1, 5

• Sit upright and lean the head forward to prevent blood from entering the airway or stomach 1, 5
• Breathe through the mouth and spit out any blood rather than swallowing it 4, 1
• After 15 minutes of compression, if bleeding slows but hasn't stopped, blow the nose once to clear clots, then spray oxymetazoline (Afrin) or phenylephrine 2 sprays into the bleeding nostril 4, 1
• Continue holding pressure for another 5-10 minutes after applying the vasoconstrictor 4, 1

When to Seek Emergency Care Immediately

Go to the emergency department if bleeding continues despite 15-30 minutes of proper compression, or if you experience lightheadedness, weakness, difficulty breathing, or feel faint. 1

• Seek emergency care for signs of significant blood loss including hemodynamic instability or hemoglobin drop ≥2 g/dL 1, 6
• The combination of Eliquis and Plavix significantly increases bleeding risk, so lower threshold for seeking care 2, 3

Medical Management in the Emergency Department

For non-life-threatening epistaxis, continue both anticoagulants and use local hemostatic measures first. 4, 1

• Perform anterior rhinoscopy after clot removal to identify the bleeding site 1, 5
• Apply nasal cautery (chemical or electrical) to the identified bleeding point after adequate anesthesia 1, 5, 7
• If packing becomes necessary, use only resorbable/absorbable packing materials (such as Nasopore, Surgicel, or Floseal) in patients on anticoagulants and antiplatelets 4, 1, 7
• Non-resorbable packing materials should be avoided in patients on dual antiplatelet/anticoagulant therapy 4

Medication Management Algorithm

Do NOT stop Eliquis or Plavix for minor to moderate epistaxis, as the thrombotic risk from discontinuation outweighs the bleeding risk. 1, 2, 3

For Non-Life-Threatening Bleeding:

• Continue both medications without interruption 1
• Contact the prescribing physician to inform them of the bleeding episode, but do not wait for their response to seek emergency care if needed 4, 2, 3
• The prescribing physician must be involved in any decision about medication changes 1

For Life-Threatening Bleeding Only:

• Stop both Eliquis and Plavix immediately if there is hemodynamic instability, ongoing severe bleeding despite packing, or hemoglobin drop ≥2 g/dL 1, 6
• Provide volume resuscitation and supportive care 1, 6
• Consider reversal agents: 4-factor prothrombin complex concentrate or andexanet alfa for Eliquis reversal 1, 6
• Note that no specific reversal agent exists for Plavix; desmopressin may be considered 8

Critical Pitfalls to Avoid

Never discontinue anticoagulation for minor epistaxis without consulting the prescribing physician, as patients are typically on these medications to prevent stroke, heart attack, or life-threatening blood clots. 1, 2, 3

• The FDA labels for both medications explicitly warn that stopping them increases risk of stroke and cardiovascular events 2, 3
• Patients with atrial fibrillation who stop Eliquis have markedly increased stroke risk 2
• Patients who stop Plavix after recent stent placement or acute coronary syndrome have increased risk of heart attack and death 3

Post-Treatment Care and Prevention

After bleeding stops, apply petroleum jelly or nasal saline gel to the nasal mucosa 2-3 times daily for at least one week to prevent recurrence. 4, 1, 5

• Avoid nose blowing, strenuous activity, heavy lifting, or placing tissues/cotton in the nose for at least 7 days 4, 1
• Use a bedside humidifier to keep nasal mucosa moist 4
• Avoid NSAIDs (ibuprofen, naproxen) and aspirin for pain; use acetaminophen instead 6
• Do not take additional aspirin beyond what is prescribed, as this further increases bleeding risk 2, 3

Follow-Up Requirements

Patients requiring nasal packing, cauterization, or any invasive intervention should have documented follow-up within 30 days to assess for complications and recurrent bleeding. 4

• Return immediately for fever >101°F, vision changes, facial swelling, severe headache, or recurrent bleeding 1
• Recurrence rates vary: <10% for surgical interventions, up to 50% for nasal packing alone 5