How to manage a female patient with nasal bleeding while on Eliquis (apixaban), an anticoagulant?

Management of Nasal Bleeding in a Female Patient on Eliquis (Apixaban)

Since the bleeding has already been controlled at home, continue Eliquis without interruption and focus on preventing recurrence through local measures and identifying any underlying causes. 1

Immediate Assessment

• Confirm that the bleeding has truly stopped and assess for signs of ongoing or recurrent bleeding by checking for active nasal drainage, blood in the oropharynx, or hemodynamic instability 1
• Verify hemodynamic stability by checking vital signs—blood pressure, heart rate, and orthostatic changes—to rule out significant blood loss 1, 2
• Obtain a complete blood count to assess for anemia (hemoglobin drop ≥2 g/dL would indicate major bleeding) and check platelet count, as thrombocytopenia increases bleeding risk 1, 3

Continue Anticoagulation

The American Academy of Otolaryngology-Head and Neck Surgery strongly recommends continuing Eliquis in patients with non-life-threatening epistaxis that has been controlled, as the thrombotic risk from stopping anticoagulation outweighs the bleeding risk. 1

• Do not withhold, reverse, or discontinue Eliquis for epistaxis that has been controlled at home, as this increases the risk of stroke or thromboembolism without improving outcomes 1
• Reversal agents (andexanet alfa) and blood products should be reserved only for life-threatening bleeding with hemodynamic instability, not for controlled epistaxis 1

Review Concomitant Medications

• Assess whether the patient is taking any antiplatelet agents (aspirin, clopidogrel, NSAIDs) that could be safely discontinued, as these significantly increase bleeding risk when combined with Eliquis 1
• If the patient is on dual antiplatelet therapy plus Eliquis, consider stopping one antiplatelet agent if medically appropriate, though this decision depends on the indication (e.g., recent stent placement) 1

Preventive Measures and Patient Education

• Instruct the patient on proper first-aid technique for future episodes: lean forward (not backward) to prevent blood aspiration, and apply firm continuous pressure to the soft part of the nose (nasal alae against the septum) for 10-15 minutes without releasing 4, 2
• Apply topical nasal moisturizers or saline gel twice daily to prevent mucosal drying and crusting, which are common triggers for recurrent epistaxis 1, 2
• Advise humidification of the home environment, especially during dry winter months or in arid climates 2, 5
• Counsel the patient to avoid nose picking, forceful nose blowing, and nasal trauma 2, 5

When to Seek Immediate Medical Attention

• Instruct the patient to return immediately if bleeding recurs and cannot be controlled with 15-20 minutes of continuous nasal compression 2, 5
• Warn about signs of major bleeding: hemodynamic instability (lightheadedness, syncope, tachycardia), large volume blood loss, or bleeding that persists despite proper compression 1
• If recurrent epistaxis occurs within 10 days, the patient should be evaluated for cauterization of a visible bleeding vessel or consideration of nasal packing 1, 2

Identify and Address Underlying Causes

• Check blood pressure, as uncontrolled hypertension is a common and modifiable risk factor for recurrent epistaxis 2, 5
• Consider ENT referral if epistaxis recurs frequently, as this may indicate a prominent vessel requiring cauterization or an underlying nasal pathology (telangiectasias, tumors) 1, 2

Critical Pitfalls to Avoid

• Never discontinue Eliquis for controlled epistaxis, as the stroke risk far exceeds the bleeding risk—patients with atrial fibrillation have a 5-fold increased stroke risk when anticoagulation is stopped 1, 6
• Do not instruct the patient to tilt the head backward, as this is a common error that increases aspiration risk and does not improve hemostasis 4, 2
• Avoid applying pressure to the nasal bridge or bony dorsum, as this does not compress the bleeding vessels in the anterior septum where 90% of epistaxis originates 4, 2
• Do not administer reversal agents (andexanet alfa) or prothrombin complex concentrates for non-life-threatening epistaxis, as these carry significant thrombotic risks without proven benefit in this setting 1

Role of Tranexamic Acid

• Topical tranexamic acid applied to the nasal cavity may reduce the risk of re-bleeding in the 10-day period after an epistaxis episode, though the evidence is moderate quality 7
• This is an adjunctive measure and should not replace proper nasal compression technique or continuation of Eliquis 7