What is the cause of epistaxis (nosebleed) with associated bleeding from the eye in a patient taking Eliquis (apixaban)?

From the Guidelines

Bleeding from the eye associated with epistaxis (nosebleed) while taking Eliquis (apixaban) is a serious medical emergency requiring immediate medical attention, and the patient should stop the Eliquis and seek emergency care right away. This combination suggests blood may be flowing backward through the nasolacrimal duct, connecting the nose to the eye, due to severe epistaxis. Eliquis, being a direct oral anticoagulant that inhibits factor Xa, prevents blood clotting and can significantly increase bleeding risk, as noted in the clinical practice guideline for nosebleed (epistaxis) 1.

Immediate Management

For immediate management, the patient should apply gentle pressure to the nose by pinching the soft part for 10-15 minutes while sitting upright and leaning slightly forward. Do not tilt your head back as this may cause blood to flow into the throat. Avoid blowing your nose, straining, or heavy lifting. The clinical practice guideline: nosebleed (epistaxis) executive summary also emphasizes the importance of prompt medical attention for severe or recurrent nosebleeds, especially in patients on anticoagulation therapy 2, 3.

Hospital Treatment

Once at the hospital, treatment may include stopping the anticoagulant, local measures to control bleeding, and possibly reversal agents like andexanet alfa in severe cases, as outlined in the clinical practice guideline for nosebleed (epistaxis) 4, 5, 6, 7. The use of reversal strategies, such as plasma, cryoprecipitate, and platelet transfusions, exposes patients to blood products and their associated risks, and should be considered carefully 7.

Long-term Management

After the emergency is resolved, the doctor will reassess whether to restart Eliquis or switch to an alternative medication based on the patient's specific risk factors for both bleeding and clotting. The management of nosebleeds in patients taking anticoagulation medications, such as Eliquis, requires careful consideration of the risks and benefits of continuing or stopping the medication, as well as the use of reversal agents if necessary, as noted in the clinical practice guideline for nosebleed (epistaxis) 1, 7.

From the FDA Drug Label

Apixaban can cause bleeding which can be serious and rarely may lead to death. You may have a higher risk of bleeding if you take apixaban tablets and take other medicines that increase your risk of bleeding, including: Call your doctor or get medical help right away if you have any of these signs or symptoms of bleeding when taking apixaban tablets: unexpected bleeding, or bleeding that lasts a long time, such as: unusual bleeding from the gums nosebleeds that happen often menstrual bleeding or vaginal bleeding that is heavier than normal bleeding that is severe or you cannot control red, pink, or brown urine red or black stools (looks like tar) cough up blood or blood clots vomit blood or your vomit looks like coffee grounds unexpected pain, swelling, or joint pain headaches, feeling dizzy or weak

The question of epistaxis causing bleeding from the eye in the setting of taking Eliquis (apixaban) is related to the risk of bleeding associated with apixaban. Bleeding is a known side effect of apixaban, and it can be serious. While the label does mention nosebleeds as a sign of bleeding, it does not specifically address bleeding from the eye. However, given the increased risk of bleeding with apixaban, it is possible that epistaxis could lead to bleeding from the eye in some cases.

• Key points to consider:
  • Apixaban increases the risk of bleeding
  • Bleeding can be serious and rarely may lead to death
  • Patients taking apixaban should be monitored for signs and symptoms of bleeding
  • If bleeding occurs, patients should seek medical attention immediately 8

From the Research

Epistaxis and Eliquis

• Epistaxis, or nosebleed, is a common condition that can be caused by various factors, including anticoagulant therapy such as Eliquis (apixaban) 9, 10.
• The management of epistaxis in patients on anticoagulant therapy, including Eliquis, is complex and requires a multidisciplinary approach 9, 11.
• There is limited guidance available on the management of antithrombotic therapy during epistaxis, and further high-quality research is needed 9, 10.

Bleeding from the Eye

• There is no direct evidence in the provided studies that suggests epistaxis can cause bleeding from the eye in patients taking Eliquis.
• However, it is possible that severe epistaxis could lead to increased pressure or trauma to the face, which may potentially cause bleeding from the eye, although this is not explicitly stated in the studies.

Management of Epistaxis in Patients on Eliquis

• The management of epistaxis in patients on Eliquis or other novel oral anticoagulants (NOACs) requires careful consideration of the patient's individual risk factors and the potential benefits and risks of reversing anticoagulation 10.
• A treatment algorithm for oral anticoagulant and antiplatelet therapy in epistaxis patients has been proposed, which takes into account the patient's specific medication regimen and clinical presentation 11.
• Clinicians should be aware of the potential severity of epistaxis and the increased likelihood of recurrence in patients on NOACs, including Eliquis 10.