What are the management options for a patient on anticoagulant (blood thinner) therapy presenting with epistaxis (nose bleed)?

From the Guidelines

For a patient on blood thinners experiencing a nosebleed, the first step is to apply firm pressure to the soft part of the nose for 10-15 minutes while sitting upright and leaning slightly forward, as recommended by the 2024 American Heart Association guidelines 1. This approach is crucial in managing epistaxis, especially in patients on anticoagulant or antiplatelet medication.

• The patient should sit with their head slightly forward with their nostrils pinched for 10 to 15 minutes, as this can help stop the bleeding.
• If the bleeding does not stop after 15 minutes of continuous manual pressure, or if the patient becomes lightheaded, they should seek medical attention immediately, as advised by the guidelines 1.
• Additionally, using a saline nasal spray or water-based lubricant to keep nasal passages moist may be recommended by a healthcare provider for recurrent nosebleeds, as suggested in the clinical practice guideline on nosebleed management 1.
• It is essential to note that patients on blood thinners should not stop taking their prescribed medication without consulting their healthcare provider, as this could increase the risk of dangerous clots.
• The use of reversal strategies, such as plasma, cryoprecipitate, and platelet transfusions, should be considered with caution, as they expose patients to blood products and their associated risks, as highlighted in the clinical practice guideline 1.
• The patient should inform all healthcare providers about their blood thinner use and carry medical identification indicating this medication.
• If the bleeding persists or is severe, the patient should seek immediate medical attention, and the healthcare provider may consider temporarily adjusting the blood thinner dosage if nosebleeds are frequent or severe.

From the FDA Drug Label

Apixaban tablets increases the risk of bleeding and can cause serious, potentially fatal, bleeding [see Dosage and Administration (2. 1) and Adverse Reactions (6.1)]. Concomitant use of drugs affecting hemostasis increases the risk of bleeding. Advise patients of signs and symptoms of blood loss and to report them immediately or go to an emergency room. Discontinue apixaban tablets in patients with active pathological hemorrhage.

The patient on apixaban with a nose bleed is at risk of serious bleeding. Discontinuation of apixaban should be considered in patients with active pathological hemorrhage, such as a nose bleed. Patients should be advised to report signs and symptoms of blood loss immediately. 2

From the Research

Management of Epistaxis in Patients on Blood Thinners

• Epistaxis, or nosebleed, is a common condition that can be complicated by the use of blood thinners, also known as anticoagulants or antiplatelet agents 3, 4, 5, 6, 7.
• The management of epistaxis in patients on blood thinners is challenging due to the increased risk of bleeding and the lack of available reversal agents for some anticoagulants 3, 7.

Comparison of Anticoagulants

• Studies have compared the management and outcome of epistaxis in patients on different types of anticoagulants, including warfarin, direct oral anticoagulants (DOACs) such as rivaroxaban and dabigatran, and antiplatelet agents 4, 5, 6.
• One study found that epistaxis in patients on DOACs was not more severe or requiring more invasive therapy compared to those on warfarin 4.
• Another study found that patients on rivaroxaban had fewer hospital admissions and shorter hospital stays compared to those on phenprocoumon, a vitamin K antagonist 6.

Treatment and Outcome

• The treatment of epistaxis in patients on blood thinners may involve cessation of anticoagulant therapy, use of reversal agents, and supportive care such as nasal packing and cauterization 5, 7.
• The outcome of epistaxis in patients on blood thinners can be favorable, with one study finding that cessation of factor Xa inhibitor therapy was effective and uneventful with no further epistaxis events 5.
• However, patients on novel oral anticoagulation therapy may be at increased risk of recurrence and may require closer monitoring and follow-up 7.

Recommendations for Management

• Clinicians should be aware of the potential severity of epistaxis and the increased likelihood of recurrence in patients on blood thinners 7.
• Recommendations for the management of epistaxis in patients on novel oral anticoagulation therapy include the use of reversal agents such as idarucizumab for dabigatran-associated bleeding, and supportive care such as nasal packing and cauterization 7.
• High-quality studies are needed to determine the efficacy and safety of new reversal agents and non-specific reversal agents 7.