What alternative anticoagulant can be started in an elderly female patient with nasal bleeding while taking Eliquis (apixaban)?

Managing Recurrent Nasal Bleeding in an Elderly Female on Eliquis

Do not switch anticoagulants—continue Eliquis and implement aggressive nasal moisturization strategies, as the thrombotic risk from changing or stopping anticoagulation far outweighs the bleeding risk from controlled epistaxis. 1

Primary Recommendation: Continue Current 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, as this increases the risk of stroke or thromboembolism without improving outcomes. 1

• Patients with atrial fibrillation have a 5-fold increased stroke risk when anticoagulation is stopped—this mortality risk is substantially higher than the morbidity from recurrent epistaxis. 1

Implement Preventive Measures First

Before considering any anticoagulant switch, aggressive local management should be the priority:

• Apply topical nasal moisturizers (petroleum jelly) or saline gel twice daily to prevent mucosal drying and crusting, which are common triggers for recurrent epistaxis. 2, 1

• Regular use of saline nasal sprays is recommended to keep the nasal mucosa moist. 2

• If a specific bleeding site is identified on examination, nasal cautery should be considered—but avoid bilateral simultaneous septal cautery as it may increase risk of septal perforation. 2

• Tranexamic acid has shown efficacy in reducing epistaxis in patients with hereditary hemorrhagic telangiectasia and may be considered off-label for recurrent epistaxis. 2

If Anticoagulant Switch is Absolutely Necessary

Only if epistaxis becomes life-threatening, hemodynamically unstable, or requires repeated hospitalizations despite optimal local management should alternative anticoagulation be considered:

Option 1: Switch to Warfarin (Vitamin K Antagonist)

• Warfarin may be considered as it allows for precise INR monitoring and dose adjustment to target the lower end of therapeutic range (INR 1.5-2.0) in high bleeding risk patients. 3

• For patients with persistent bleeding risk during anticoagulation in the therapeutic range, a target INR of 2.0 to 2.5 (lower than standard 2.0-3.0) is sensible for atrial fibrillation. 3

• Warfarin has the advantage of reversibility with vitamin K and is the drug with which we have the most clinical experience managing bleeding complications. 4

• To switch from Eliquis to warfarin: discontinue apixaban and begin both a parenteral anticoagulant (such as enoxaparin) and warfarin at the time the next dose of apixaban would have been taken, discontinuing the parenteral anticoagulant when INR reaches an acceptable range. 5

Option 2: Consider Lower-Dose Dabigatran

• Dabigatran 110 mg twice daily (rather than 150 mg) is recommended in elderly patients age ≥80 years and those with high bleeding risk (HAS-BLED score ≥3). 3

• In real-world studies, dabigatran was associated with lower major bleeding risk compared with warfarin (HR 0.67,95% CI 0.60-0.76) and rivaroxaban (HR 0.67,95% CI 0.58-0.78). 6

• However, dabigatran has a higher risk of major gastrointestinal bleeding compared to apixaban (HR 1.43,95% CI 1.09-1.88), though nasal bleeding patterns may differ. 6

• To switch from Eliquis to dabigatran: discontinue apixaban and begin taking dabigatran at the usual time of the next dose of apixaban. 5

Option 3: Rivaroxaban is NOT Recommended

• Rivaroxaban showed similar major bleeding risk to warfarin in real-world studies and was associated with significantly higher bleeding rates than apixaban. 6

• The unadjusted rate of major bleeding with rivaroxaban was 5.0 per 100 person-years versus 3.3 with apixaban. 6

Critical Considerations for Elderly Patients

• In elderly patients with renal impairment (common in this population), apixaban actually has a favorable bleeding profile—bleeding risk with apixaban in patients with mild renal impairment was significantly less (RR 0.80,95% CI 0.66-0.96) compared with conventional anticoagulants. 7

• Assess renal function (creatinine clearance) before any switch, as this affects dosing and bleeding risk for all DOACs. 3

• Document other bleeding risk factors including hypertension, concomitant antiplatelet use, and body weight ≤60 kg. 3, 2

When to Seek Immediate Evaluation

• If recurrent epistaxis occurs within 10 days despite preventive measures, the patient should be evaluated for cauterization of a visible bleeding vessel or consideration of nasal packing. 1

• Warn about signs of major bleeding: hemodynamic instability (lightheadedness, syncope, tachycardia), large volume blood loss, or bleeding that persists despite proper compression. 1

Common Pitfalls to Avoid

• Never discontinue Eliquis for controlled epistaxis without providing alternative anticoagulation coverage—the stroke risk far exceeds the bleeding risk. 1, 5

• 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. 3, 1

• Do not underestimate the importance of simple measures like nasal moisturization, which can be highly effective in preventing recurrence and avoid the need for anticoagulant switching altogether. 2

• Avoid switching to rivaroxaban, as it has higher bleeding rates than apixaban in real-world data. 6