How to manage epistaxis (nosebleed) in patients taking Non-Steroidal Anti-Inflammatory Drugs (NSAIDs)?

Management of Epistaxis in Patients Taking NSAIDs

In patients taking NSAIDs who develop epistaxis, apply the same standard epistaxis management protocol without discontinuing the NSAID unless bleeding cannot be controlled with local measures, recognizing that NSAIDs cause significant platelet dysfunction that increases bleeding risk. 1, 2

Initial Management Approach

First-Line Treatment (Same for All Patients)

• Position the patient sitting upright with head tilted slightly forward to prevent blood from entering the airway or stomach 3
• Apply firm, continuous pressure to the soft lower third of the nose for a full 10-15 minutes without checking if bleeding has stopped 3
• Have the patient breathe through their mouth and spit out blood rather than swallowing it 3
• Compression alone resolves the vast majority of anterior epistaxis cases, even in patients on NSAIDs 3

Second-Line Treatment (If Bleeding Continues After 15 Minutes)

• Clear clots from the nasal cavity 3
• Apply topical vasoconstrictor (oxymetazoline or phenylephrine) - 2 sprays into the bleeding nostril 3, 4
• Resume firm compression for another 5-10 minutes 3
• Vasoconstrictor application stops bleeding in 65-75% of cases treated in the emergency department 3, 4

Special Considerations for NSAID-Related Epistaxis

Understanding the Platelet Dysfunction

• NSAIDs produce significant platelet dysfunction through antiplatelet effects, which should be considered in the multifactorial etiology of epistaxis 1, 2
• Patients with epistaxis show a significant increase in NSAID intake and demonstrate significant reduction in platelet aggregation to collagen compared to controls 2
• The antiplatelet effects are in addition to any direct mucosal effects 1

When to Consider Stopping NSAIDs

• Do NOT routinely discontinue NSAIDs for epistaxis - NSAIDs should be avoided in persons with preexisting platelet defects or thrombocytopenia, but standard epistaxis alone is not an indication to stop 1
• Consider stopping NSAIDs only if bleeding cannot be controlled with local measures (compression, vasoconstrictors, cautery, and packing) 3
• For aspirin specifically: if the patient is at high risk of cardiovascular events (recent MI or recent cardiac stent), aspirin should be continued despite epistaxis 1
• For other NSAIDs: if discontinuation is necessary perioperatively or for severe bleeding, withhold for five elimination half-lives (e.g., ibuprofen for 2 days, naproxen for 2-3 days) 1

Advanced Treatment Options

Nasal Packing (If Bleeding Persists After 15-30 Minutes)

• Use resorbable/absorbable packing materials only in patients on NSAIDs (Nasopore, Surgicel, Floseal) to reduce trauma during removal 3
• This is critical because the antiplatelet effects of NSAIDs increase bleeding risk during pack removal 3

Topical Tranexamic Acid (Alternative to Standard Vasoconstrictors)

• Topical tranexamic acid is superior to phenylephrine-lidocaine in patients on antiplatelet agents, with mean time to stop bleeding of 6.70 minutes versus 11.50 minutes 5
• Bleeding recurrence occurs in only 6% with tranexamic acid versus 20% with standard packing in antiplatelet users 5
• Tranexamic acid promotes hemostasis in 78% of patients versus 35% with oxymetazoline 6
• This represents a particularly valuable option for NSAID users given their platelet dysfunction 5

Cauterization (If Bleeding Site Identified)

• Electrocautery is more effective with fewer recurrences (14.5%) compared to chemical cauterization (35.1%) 6
• Can be performed after vasoconstrictor application if bleeding source is visualized 3

Prevention of Recurrence

• Apply petroleum jelly or lubricating agents to nasal mucosa once bleeding stops 3
• Recommend regular use of saline nasal sprays to keep mucosa moist 3
• Use humidifiers in dry environments 3
• Avoid nasal manipulation and vigorous nose-blowing for 7-10 days 3

Critical Pitfalls to Avoid

• Insufficient compression time: Must maintain pressure for full 10-15 minutes without checking - this is the most common error 3
• Premature NSAID discontinuation: Do not stop NSAIDs reflexively; most epistaxis resolves with local measures alone 1, 3
• Using non-resorbable packing in NSAID users: Always use absorbable materials due to increased bleeding risk during removal 3
• Stopping aspirin in high-risk cardiovascular patients: The survival benefits outweigh bleeding risks in patients with recent MI or stents 1

When to Escalate Care

• Bleeding not controlled after 15 minutes of continuous pressure with vasoconstrictors requires nasal packing 3
• Hemodynamic instability (tachycardia, hypotension) requires immediate hospitalization 3
• Severe bleeding (duration >30 minutes over 24 hours) requires hospitalization 3
• If nasal packing fails, consider endoscopic sphenopalatine artery ligation (97% success rate) or endovascular embolization (80% success rate) 6

Anticoagulation Interaction Warning

• When NSAIDs are combined with anticoagulants, there is a three- to sixfold increased risk of GI bleeding, and this principle extends to mucosal bleeding sites 1
• If patient is on both NSAIDs and warfarin, expect INR to increase by up to 15% 1
• In patients on both NSAIDs and anticoagulants with epistaxis, do not reverse anticoagulation unless bleeding is life-threatening and uncontrolled with local measures 3