Can Pseudoephedrine Cause Epistaxis?
Pseudoephedrine does not directly cause epistaxis through its pharmacologic mechanism; rather, it is used as a topical vasoconstrictor to treat nosebleeds. However, the documented adverse effects of oral pseudoephedrine—including elevated blood pressure, palpitations, irritability, tremor, and sleep disturbance—do not include epistaxis as a recognized side effect 1.
Mechanism and Clinical Use
- Pseudoephedrine functions as an α-adrenergic agonist causing systemic and local vasoconstriction 1.
- Topical vasoconstrictors (including phenylephrine and other sympathomimetics) are actually recommended as first-line treatments for epistaxis, used to control nasal bleeding through their vasoconstrictive properties 1.
- The American Academy of Otolaryngology-Head and Neck Surgery guidelines explicitly recommend topical vasoconstrictors as part of initial epistaxis management, alongside nasal compression, cautery, and packing 1.
Evidence from Adverse Effect Literature
- A comprehensive 2018 review of drug-induced epistaxis identified anticoagulants (warfarin, dabigatran, rivaroxaban), antiplatelet agents (aspirin, clopidogrel), selective serotonin reuptake inhibitors, intranasal corticosteroids, and certain antibiotics as causative agents 2.
- Pseudoephedrine was notably absent from this systematic review of medications causing epistaxis 2.
- The documented adverse effects of oral pseudoephedrine in multiple guideline sources consistently list cardiovascular effects (blood pressure elevation, tachycardia), central nervous system effects (insomnia, irritability, tremor), and appetite suppression—but not epistaxis 1.
Cardiovascular Effects vs. Nasal Bleeding
- Pseudoephedrine increases systolic blood pressure by approximately 0.99 mmHg (95% CI, 0.08-1.90) and heart rate by 2.83 beats/min (95% CI, 2.0-3.6) 1, 3.
- While hypertension itself has been associated with epistaxis (OR 1.532; 95% CI, 1.181-1.986), no causal relationship has been established, and the modest blood pressure elevation from pseudoephedrine would not be expected to trigger nosebleeds 1.
Topical Decongestants and Nasal Effects
- Topical decongestants (phenylephrine, oxymetazoline, xylometazoline) may cause local stinging, burning, sneezing, and dryness of the nose and throat—but epistaxis is not listed as an adverse effect 1.
- The primary concern with topical decongestants is rhinitis medicamentosa with prolonged use (>3 days), not bleeding 1.
Clinical Bottom Line
Pseudoephedrine should not be considered a cause of epistaxis. If a patient presents with nosebleeds while taking pseudoephedrine, investigate other causes including: