What could be causing nose bleeding in a patient taking Ritalin (methylphenidate) 5mg daily, Zoloft (sertraline) 100mg, Quetiapine (quetiapine) 25mg, and Xanax (alprazolam) PRN (as needed), after recently discontinuing Vyvanse (lisdexamfetamine) and increasing the Zoloft dose?

Medication-Induced Epistaxis: Sertraline as the Primary Culprit

The nosebleeds are most likely caused by the increased Zoloft (sertraline) dose to 100mg, as SSRIs like sertraline significantly increase bleeding risk by impairing platelet function, and this temporal relationship (bleeding starting after the dose increase) strongly implicates sertraline as the causative agent. 1

Why Sertraline is the Most Likely Cause

SSRIs, including sertraline, increase the risk of bleeding events ranging from epistaxis to life-threatening hemorrhage by interfering with platelet serotonin reuptake, which is essential for normal platelet aggregation. 1 The FDA drug label explicitly warns that sertraline "may increase your risk of bleeding or bruising" and that "abnormal bleeding" is a documented serious side effect. 1

• The temporal relationship is critical here: the epistaxis began specifically after increasing sertraline from a lower dose to 100mg, making this the most plausible explanation. 1
• Case reports document sertraline-induced acquired thrombopathy (platelet dysfunction) causing recurrent epistaxis, with abnormal platelet function tests during sertraline exposure. 2
• The bleeding mechanism involves impaired platelet secretion and aggregation, not anticoagulation, which explains why standard coagulation tests may be normal. 2

Why Other Medications Are Less Likely Responsible

Ritalin (methylphenidate) 5mg is an unlikely cause because:

• Stimulants can cause nasal dryness and local irritation with chronic intranasal use, but oral methylphenidate at low doses (5mg) rarely causes epistaxis. 3
• The patient was previously on Vyvanse (another stimulant) without reported bleeding issues, making stimulant-induced epistaxis less likely. 3

Quetiapine 25mg and Xanax PRN are not associated with increased bleeding risk and do not affect platelet function or coagulation pathways. 4, 3

Immediate Management Approach

First-line treatment should focus on direct nasal compression for 10-15 minutes while sitting upright with head tilted slightly forward, followed by topical vasoconstrictors if bleeding persists. 5

Step-by-step management:

1. Position the patient sitting upright with head tilted slightly forward to prevent blood from entering the airway. 5

2. Apply firm sustained compression to the soft lower third of the nose for at least 10-15 minutes without checking if bleeding has stopped. 5

3. If bleeding persists after compression, apply oxymetazoline or phenylephrine spray (2 sprays in the bleeding nostril), which resolves 65-75% of cases. 5

4. Perform anterior rhinoscopy after removing blood clots to identify the bleeding site. 4, 3

5. If a specific bleeding site is identified, perform nasal cautery after topical anesthesia with lidocaine. 3

Medication Management Strategy

Do not discontinue sertraline abruptly, as this can cause serious withdrawal symptoms including dysphoric mood, irritability, and sensory disturbances. 1

Recommended approach:

• Consider reducing sertraline dose gradually (e.g., back to 50mg or lower) rather than abrupt discontinuation, as the bleeding risk is dose-dependent. 1
• First-line treatments should be initiated before considering medication adjustments, meaning control the acute bleeding first. 5
• If epistaxis is severe or recurrent despite local measures, a gradual sertraline taper may be necessary, but this should be balanced against psychiatric stability. 1

Prevention of Recurrence

Once bleeding stops, apply petroleum jelly or other moisturizing agents to the nasal mucosa and prescribe regular saline nasal sprays to maintain mucosal moisture. 5

• Recommend using a humidifier, especially in dry environments. 3
• Avoid NSAIDs, aspirin, or other antiplatelet agents, as these dramatically increase bleeding risk when combined with sertraline. 1

Critical Red Flags Requiring Emergency Evaluation

Seek immediate medical attention if:

• Bleeding does not stop after 15 minutes of continuous pressure. 5
• The patient experiences dizziness, tachycardia, or signs of hemodynamic instability. 3, 5
• Bleeding is severe (duration >30 minutes over a 24-hour period). 3, 5

Common Pitfalls to Avoid

• Do not add NSAIDs or aspirin for any reason, as the combination with sertraline creates additive bleeding risk. 1
• Do not stop sertraline abruptly without a tapering plan, as withdrawal symptoms can be severe. 1
• Do not assume normal coagulation studies rule out sertraline-induced bleeding, as the mechanism involves platelet dysfunction, not coagulation factor deficiency. 2
• Insufficient compression time is a common error—compression must be maintained for the full 10-15 minutes without checking. 5

Documentation Requirements

Document the following risk factors as recommended by the American Academy of Otolaryngology-Head and Neck Surgery:

• Complete medication list including all doses and recent changes. 4
• Personal or family history of bleeding disorders. 4
• Any intranasal drug use or nasal oxygen/CPAP use. 3