How to manage anterior epistaxis in a patient on Rivaroxaban (Xarelto)

Management of Anterior Epistaxis in Patients on Rivaroxaban

For anterior epistaxis in patients on rivaroxaban, continue the anticoagulant and apply local hemostatic measures (direct pressure, topical vasoconstrictors, and cautery) if bleeding is minor and easily controlled; only discontinue rivaroxaban temporarily if bleeding is severe, recurrent, or requires hospitalization, transfusion, or procedural intervention. 1, 2

Initial Assessment and Classification

Determine if the epistaxis meets criteria for major bleeding, defined as: 1, 2

• Bleeding requiring hospitalization, procedural intervention, or transfusion of ≥2 units of red blood cells
• Hemodynamic instability (hypotension, tachycardia)
• Hemoglobin decrease ≥2 g/dL
• Bleeding at a critical anatomical site

Most anterior epistaxis cases will be classified as non-major bleeding and can be managed without interrupting rivaroxaban. 1, 2

Management for Non-Major Anterior Epistaxis

Continue Rivaroxaban

If hemostasis has been achieved and the patient does not require hospitalization, procedure, or transfusion, continue rivaroxaban without interruption. 1, 2

Local Hemostatic Measures

Apply the following interventions sequentially: 1, 2, 3

• Direct pressure: Pinch the soft part of the nose for at least 5-10 minutes 1, 2
• Topical vasoconstrictors: Apply oxymetazoline (Afrin) spray or cotton pledgets soaked in vasoconstrictor to the bleeding site 1, 2
• Anesthesia and visualization: Use topical lidocaine or tetracaine with vasoconstrictor on cotton pledgets, then perform anterior rhinoscopy after removing blood clots 1, 2
• Chemical cautery: Apply silver nitrate cautery only to the identified bleeding site after adequate anesthesia—this has the highest success rate (80%) and requires no follow-up 1, 4
• Topical tranexamic acid: Consider gauze soaked in tranexamic acid as an adjunctive local hemostatic agent 1

Avoid bilateral cautery to minimize risk of septal perforation. 1

Concomitant Antiplatelet Management

If the patient is on aspirin, clopidogrel, or other antiplatelet agents in addition to rivaroxaban: 1, 2

• Weigh the risk versus benefit of temporarily discontinuing antiplatelet agents
• Note that irreversible antiplatelet agents (aspirin, clopidogrel, prasugrel) have a duration of action such that temporary discontinuation may not have clinical effect for several days
• Ticagrelor is an exception with a half-life of 7-9 hours and may be more amenable to temporary discontinuation

Management for Major or Recurrent Anterior Epistaxis

Discontinue Rivaroxaban Temporarily

Stop rivaroxaban immediately if: 1, 2

• Bleeding is severe, recurrent, or difficult to control
• Patient requires hospitalization, nasal packing, or procedural intervention
• Patient requires transfusion of ≥2 units of red blood cells
• Hemodynamic instability is present
• Hemoglobin has decreased ≥2 g/dL

Advanced Local Measures

• Nasal packing: Use anterior nasal packing (Merocel or petroleum gauze) for persistent bleeding, though these have higher recurrence rates (26-42%) compared to cautery 2, 4
• Endoscopic cautery: Consider for bleeding sites not amenable to office-based cautery 1

Reversal Strategies

For life-threatening or uncontrolled bleeding: 1, 2

• Andexanet alfa (specific reversal agent for rivaroxaban):

  • Low-dose regimen: 400 mg IV bolus followed by 4 mg/min infusion for up to 120 minutes if last rivaroxaban dose ≤10 mg was taken <8 hours prior or timing unknown 1
  • High-dose regimen: 800 mg IV bolus followed by 8 mg/min infusion for up to 120 minutes if last rivaroxaban dose >10 mg was taken <8 hours prior 1

• If andexanet alfa is unavailable: Administer prothrombin complex concentrate (PCC) or activated PCC (aPCC) 1, 2

• Activated charcoal: Consider if rivaroxaban was taken within 2-4 hours 1

Supportive Care

Provide: 1

• Volume resuscitation and hemodynamic support
• Red blood cell transfusion if indicated
• Correction of any dilutional coagulopathy

Laboratory Monitoring

Standard coagulation tests have limited utility for rivaroxaban: 2

• PT is more sensitive than aPTT but varies significantly depending on reagents used 1, 2
• These tests provide qualitative information but are not reliable for precise measurement of anticoagulant effect 2
• Check serial hemoglobin levels to detect ongoing occult bleeding 2

When to Restart Rivaroxaban

Delay restarting rivaroxaban if: 1, 2

• Patient is at high risk of rebleeding or death/disability with rebleeding
• Source of bleeding has not been definitively treated
• Surgical or invasive procedures are planned

Restart rivaroxaban when: 1, 2

• Bleeding has been controlled for 24-48 hours
• Patient has high thrombotic risk (atrial fibrillation with CHA₂DS₂-VASc ≥2, recent venous thromboembolism)
• Source of bleeding has been identified and treated
• Generally restart within 7 days if thrombotic risk is high

Preventive Measures and Patient Education

Counsel patients to: 2

• Avoid nose picking, forceful nose blowing, and straining
• Use nasal saline sprays and humidification to prevent nasal dryness
• Discontinue intranasal corticosteroids if contributing to bleeding
• Apply nasal emollients (petroleum jelly, antibiotic ointment) to prevent recurrence—though these do not stop active bleeding 1

Evaluate for drug interactions that may increase bleeding risk, particularly NSAIDs and additional antiplatelet agents. 2

Common Pitfalls

• Do not routinely discontinue rivaroxaban for minor anterior epistaxis—this increases thrombotic risk without clear benefit 1, 2
• Do not use prophylactic factor concentrates before procedures—only use reversal agents for active life-threatening bleeding 5
• Do not perform bilateral cautery—this significantly increases risk of septal perforation 1
• Do not rely on INR or aPTT to guide management—these tests do not reliably correlate with rivaroxaban levels 1, 2, 6
• Silver nitrate cautery is superior to nasal packing for anterior epistaxis with lower recurrence rates and no need for removal or follow-up 1, 4