What treatment is recommended for a patient with profuse epistaxis (nose bleeding) who has a history of epistaxis since starting Eliquis (apixaban)?

From the Guidelines

For profuse nosebleeds, especially in a patient on Eliquis (apixaban), I strongly recommend immediate application of firm pressure to the soft part of the nose for at least 10-15 minutes without interruption, as suggested by the 2024 American Heart Association and American Red Cross guidelines for first aid 1. The patient should sit upright, lean slightly forward, and breathe through the mouth.

• Apply an ice pack or cold compress to the bridge of the nose to constrict blood vessels.
• Over-the-counter options include oxymetazoline nasal spray (Afrin) which can help constrict blood vessels, but should not be used for more than 3 days.
• Saline nasal spray or petroleum jelly can help moisturize the nasal passages to prevent future bleeds. If bleeding continues after 20-30 minutes of pressure, seek immediate medical attention as the patient may need nasal packing, cauterization, or evaluation of Eliquis dosing, considering the patient's history of epistaxis while on anticoagulant medication, as recommended by the 2020 clinical practice guideline on nosebleed (epistaxis) 1. Eliquis is a blood thinner that prevents clotting, which explains the recurrent nosebleeds.
• The patient should avoid blowing her nose, picking her nose, or strenuous activity for 24 hours after the bleeding stops to prevent recurrence. Given the patient's history of epistaxis while on Eliquis, it is reasonable to seek care from a healthcare professional unless the bleeding has stopped, as suggested by the 2024 guidelines 1.

From the FDA Drug Label

The FDA drug label does not answer the question.

From the Research

Treatment Options for Nose Bleeding

• The patient has a history of epistaxis since starting Eliquis, and has been bleeding for about 3 hours, with attempts to stop the bleeding using a tissue and having her hold it, but she keeps taking it off and blowing her nose 2.
• Studies have shown that oxymetazoline, tranexamic acid, and epinephrine-lidocaine combination can be effective in treating epistaxis, with oxymetazoline showing superior efficacy in achieving rapid hemostasis and reducing recurrence 3.
• A comparative study found that topical tranexamic acid was more effective than topical oxymetazoline in achieving hemostasis in anterior epistaxis, with a higher success rate and fewer recurrences 4.
• A systematic review of the use of tranexamic acid in epistaxis found that it can be a powerful tool in managing epistaxis, with significant benefits in reducing severity and frequency of recurrent epistaxes in patients with hereditary haemorrhagic telangiectasia 5.

Management of Antithrombotic Therapy

• The patient is taking Eliquis, a direct oral anticoagulant, which can increase the risk of bleeding, and there is limited guidance available on managing antithrombotic therapy during epistaxis 6.
• A systematic review found a lack of evidence regarding the management of antithrombotic therapy during epistaxis, highlighting the need for further high-quality research in this area 6.

Recommendations

• Based on the available evidence, oxymetazoline or tranexamic acid may be considered as treatment options for the patient's epistaxis, with oxymetazoline showing superior efficacy in achieving rapid hemostasis and reducing recurrence 3, 4.
• The patient's antithrombotic therapy should be managed in consultation with a healthcare provider, taking into account the risks and benefits of continuing or discontinuing the medication 6.