In an adult taking a multivitamin who has frequent epistaxis, which vitamin deficiencies should be considered and how should they be addressed?

Vitamin Deficiencies in Frequent Epistaxis

In adults taking a multivitamin who experience frequent epistaxis, vitamin K deficiency is the primary vitamin deficiency to consider, though standard multivitamins typically provide adequate vitamin K (150 mcg) to prevent deficiency-related bleeding. 1

Primary Vitamin Deficiency Concern: Vitamin K

Vitamin K is the only vitamin deficiency directly linked to epistaxis through impaired coagulation. 1 The mechanism involves undercarboxylation of vitamin K-dependent clotting factors (prothrombin and factors VII, IX, X), leading to prolonged bleeding times. 1

When to Suspect Vitamin K Deficiency

Consider vitamin K deficiency in patients with:

• Fat malabsorption disorders (inflammatory bowel disease, cystic fibrosis, short bowel syndrome, chronic pancreatitis) 1
• Chronic antibiotic use that disrupts intestinal bacteria producing vitamin K2 1
• Severe dietary restriction or malnutrition 1
• Concurrent warfarin therapy (though this is pharmacologic antagonism, not true deficiency) 1

Diagnostic Approach

Measure PIVKA-II (protein induced by vitamin K absence) or prothrombin time/INR to assess functional vitamin K status, as these are more sensitive than direct phylloquinone levels for detecting subclinical deficiency. 1 Direct measurement of plasma phylloquinone reflects only recent intake, not tissue stores. 1

Treatment for Vitamin K Deficiency

If deficiency is confirmed:

• Oral vitamin K (phylloquinone): 10 mg intramuscularly or subcutaneously, followed by 1-2 mg/week parenterally or orally 1
• For severe bleeding with confirmed deficiency: Fresh frozen plasma or 4-factor prothrombin complex concentrate (PCC) may be required, though this is rarely necessary for simple epistaxis 1

Secondary Consideration: Vitamin E Excess (Not Deficiency)

Paradoxically, vitamin E excess—not deficiency—can cause epistaxis. 1, 2 Megadoses of vitamin E (>1000 mg/day) decrease platelet adhesiveness and interfere with vitamin K-dependent carboxylation of prothrombin, increasing bleeding risk. 1, 2

Clinical Implications

• Check if the patient is taking additional vitamin E supplements beyond their multivitamin 2
• The upper limit for vitamin E is 1000 mg/day due to hemorrhage risk 3
• Patients should discontinue vitamin E supplements if taking >400 IU daily and experiencing recurrent epistaxis 2

Other Vitamins: Unlikely Culprits

Vitamin C

Vitamin C deficiency (scurvy) can theoretically cause bleeding, but this is exceedingly rare in adults taking any multivitamin and presents with gingival bleeding, petechiae, and perifollicular hemorrhages before epistaxis. 1, 3 Standard multivitamins provide 60-90 mg, well above the 10 mg needed to prevent scurvy. 3

Vitamin A

Vitamin A deficiency does not cause epistaxis. 1 Conversely, vitamin A excess can cause mucosal drying that might predispose to nosebleeds, but this is not a direct bleeding diathesis. 1

Critical Management Principle

The 2020 American Academy of Otolaryngology guidelines emphasize that first-line epistaxis management (nasal compression, topical vasoconstrictors, cautery, packing) should NOT be delayed to reverse anticoagulation or correct vitamin deficiencies unless bleeding is life-threatening. 1 Local control measures are effective even in the presence of coagulopathy. 1

Practical Algorithm

1. Treat the epistaxis with standard local measures first (compression, oxymetazoline, cautery if bleeding site identified) 1
2. Obtain medication history including over-the-counter supplements, particularly vitamin E and anticoagulants 1, 2
3. If recurrent epistaxis despite local measures, check PT/INR and consider PIVKA-II 1
4. If fat malabsorption history exists, measure vitamin K status 1
5. Discontinue excess vitamin E if present 2
6. Supplement vitamin K only if deficiency documented 1

Common Pitfalls to Avoid

• Do not empirically supplement vitamin K without documented deficiency, as this can interfere with warfarin management if later needed 1
• Do not withhold anticoagulation medications for simple epistaxis, as thrombotic risk outweighs bleeding risk 1
• Do not overlook vitamin E excess when evaluating "vitamin problems" in epistaxis—excess, not deficiency, is the issue 2
• Do not assume multivitamins prevent all deficiencies in patients with malabsorption—fat-soluble vitamins (including K) require adequate fat absorption 1