What to do for a nosebleed after starting apixaban (eliquis)?

Management of Nosebleed After Starting Apixaban

Do not stop apixaban without consulting the prescribing physician, as the thrombotic risk from discontinuation typically outweighs the bleeding risk from minor epistaxis—instead, use local compression and hemostatic measures first. 1, 2

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. 1, 2

• Sit upright and lean the head slightly forward to prevent blood from entering the airway or stomach 2
• Breathe through the mouth and spit out any blood rather than swallowing it 1, 2
• After 15 minutes, 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 1, 2
• Continue holding pressure for another 5-10 minutes after applying the vasoconstrictor 1, 2

This approach stops bleeding in 65-75% of cases. 2

When to Seek Emergency Care

Go to the emergency department immediately if bleeding continues despite 15-30 minutes of proper compression, or if you experience lightheadedness, weakness, feeling faint, or difficulty breathing. 2

Additional red flags requiring emergency evaluation include: 1, 3

• Severe blood loss (filling a cup or more) 2
• Red, pink, or brown urine 3
• Red or black stools that look like tar 3
• Vomiting blood or vomit that looks like coffee grounds 3
• Hemoglobin drop ≥2 g/dL 2

Medical Management in the Emergency Department

For non-life-threatening epistaxis, continue apixaban and use local hemostatic measures first—only stop the medication for major/life-threatening bleeding. 1, 2

The treatment algorithm is: 2

• Perform anterior rhinoscopy to identify the bleeding site after clot removal 2
• Use nasal cautery or apply moisturizing/lubricating agents to the identified bleeding site 2
• If packing becomes necessary, use only resorbable/absorbable packing materials (such as Nasopore, Surgicel, or Floseal)—never traditional gauze packing 2

For Life-Threatening Bleeding Only

If bleeding is severe and life-threatening: 1, 2

• Stop apixaban immediately and withhold the next dose 1, 2
• Provide supportive care and volume resuscitation 2
• Consider reversal with andexanet alfa: administer high-dose regimen (800 mg IV bolus followed by 8 mg/min infusion for up to 120 minutes) if the last dose of apixaban >5 mg was taken <8 hours prior, or timing unknown 1
• If andexanet alfa is unavailable, administer 4-factor prothrombin complex concentrate (4F-PCC) or activated prothrombin complex concentrate 1

A critical caveat: reversal agents carry thrombotic risk and should only be used for truly life-threatening bleeding, not minor nosebleeds. 1

Prevention of Recurrent Episodes

Apply petroleum jelly (Vaseline) or nasal saline gel inside the nostrils 1-3 times daily for at least one week to prevent recurrence. 1, 2

Additional preventive measures include: 1, 2

• Use a bedside humidifier to keep nasal mucosa moist 2
• Avoid nose blowing, strenuous activity, and heavy lifting for at least 7 days after an episode 2
• Eliminate digital trauma (nose picking) and vigorous nose blowing 1
• Use nasal saline spray regularly 1

Critical Coordination with Prescribing Physician

The physician who prescribed apixaban must be involved in any decision about medication management—do not independently stop the medication. 1, 2, 3

Key points about apixaban and epistaxis: 2, 4

• Nosebleeds are a known and common side effect of apixaban, occurring at a rate of 26 per 100 patient-years 4
• Apixaban was prescribed to prevent stroke, heart attack, or life-threatening blood clots—stopping it significantly increases risk of these catastrophic events 3
• In most cases of minor bleeding, anticoagulation can be resumed after delaying or skipping a single dose 1

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. 1, 2

Common Pitfall to Avoid

The most dangerous error is stopping apixaban without medical consultation due to fear of minor nosebleeds—this dramatically increases stroke risk in patients with atrial fibrillation. 3 Local measures control the vast majority of epistaxis episodes without requiring anticoagulation reversal. 2