A patient taking low‑dose aspirin (Ecosprin) has significant epistaxis and gingival bleeding (~2 cups). Should the aspirin be stopped, and for how long should it be withheld?

Management of Significant Aspirin-Related Epistaxis and Gingival Bleeding

Do not stop Ecosprin (aspirin) for this bleeding episode; instead, aggressively pursue local hemostatic measures first, and only consider temporary aspirin interruption if bleeding becomes life-threatening with hemodynamic instability.

Immediate Management Priority

The cornerstone of management is aggressive local control, not aspirin discontinuation. The American Academy of Otolaryngology-Head and Neck Surgery explicitly recommends initiating first-line local treatments prior to withdrawal of antiplatelet medications in the absence of life-threatening bleeding 1, 2, 3. The cardiovascular risks of stopping aspirin—particularly stroke and myocardial infarction—often exceed the risks of continued bleeding when local measures are properly applied 1, 2.

First-Line Local Hemostatic Measures

For epistaxis:

• Apply firm, sustained compression to the soft lower third of the nose for a full 10–15 minutes without intermittent checking, with the patient seated and head tilted slightly forward, breathing through the mouth and expectorating blood 1, 2
• After compression, clean the nasal cavity of clots and apply topical vasoconstrictor (oxymetazoline or phenylephrine spray, 2 sprays), which stops bleeding in 65–75% of cases 1, 2
• If a specific bleeding site is identified on anterior rhinoscopy, perform nasal cautery using 75% silver nitrate, restricting cautery only to the active bleeding point 1, 2
• If bleeding persists despite compression, vasoconstrictors, and cautery, proceed to nasal packing using only resorbable materials (Nasopore, Surgicel, or Floseal) in patients on aspirin to avoid trauma during removal 1, 2, 3

For gingival bleeding:

• Apply direct pressure with gauze soaked in topical vasoconstrictor or tranexamic acid 4
• Place oxidized cellulose in bleeding sites if pressure alone is insufficient 5
• Local hemostatic measures are sufficient to control bleeding in patients on low-dose aspirin undergoing dental procedures 6, 5

Evidence Supporting Continuation of Aspirin

The evidence strongly favors continuing aspirin during bleeding episodes:

• In oral surgery patients on 100 mg aspirin daily, local hemostatic methods were sufficient to control bleeding in 100% of cases, with no episodes of uncontrolled intraoperative or postoperative bleeding 6
• Topical tranexamic acid in aspirin/clopidogrel users achieved hemostasis in a mean of 6.7 minutes versus 11.5 minutes with standard packing, with recurrence rates of only 6% versus 20% 4
• The American College of Cardiology guidelines state that aspirin 75–100 mg daily should be continued in patients with mechanical valves even when combined with warfarin, despite a slightly increased risk of minor bleeding such as epistaxis 7

When to Consider Temporary Aspirin Interruption

Only consider stopping aspirin if:

• Bleeding is truly life-threatening with hemodynamic instability (tachycardia, hypotension) 1, 2
• Massive hemorrhage requiring transfusion or causing airway compromise 1, 3
• Persistent severe bleeding after failure of all local hemostatic measures including nasal packing 1, 3

If aspirin must be temporarily withheld:

• The duration of interruption should be as brief as possible—typically 5–7 days maximum, corresponding to the time needed for new platelet generation 7
• Restart aspirin as soon as hemostasis is confirmed, typically within 24–48 hours after bleeding control 3
• Critical caveat: Consult cardiology before stopping aspirin in patients with recent acute coronary syndrome or coronary stents, as thrombotic risk may be prohibitively high 1

Prevention of Recurrent Bleeding

The cornerstone of preventing recurrence is aggressive nasal and oral mucosal moisturization 3:

• Apply petroleum jelly to the anterior nasal septum 1–3 times daily, particularly before bedtime 1, 2, 3
• Use regular saline nasal sprays throughout the day 1, 2, 3
• Consider bedside humidification during sleep, especially in dry climates 3
• For gingival bleeding, maintain meticulous oral hygiene and consider chlorhexidine rinses

Risk-Benefit Context

The absolute benefit of aspirin prophylaxis dramatically outweighs bleeding risk in most cardiovascular patients. For example, in patients with prior myocardial infarction, aspirin prevents 20 major vascular events per 1,000 patients per year, while causing only 1–2 major GI bleeding events per 1,000 per year 7. The mortality rate from aspirin-induced upper GI bleeding is 5–10%, but the absolute excess of major bleeds in acute MI patients is 1/100th the number of major vascular events prevented 7.

Common Pitfalls to Avoid

• Do not routinely discontinue aspirin to "see if bleeding stops"—this practice is not evidence-based and significantly increases stroke and cardiovascular event risk 1, 3
• Do not administer platelet transfusions for non-life-threatening epistaxis—the American College of Cardiology recommends against routine platelet transfusion, prioritizing aggressive local measures instead 1
• Do not underestimate simple local measures—compression, vasoconstrictors, and moisturization control bleeding in the vast majority of cases without need for aspirin discontinuation 1, 2, 6
• Do not perform bilateral nasal cautery simultaneously—this markedly increases septal perforation risk 2

When to Escalate Care

• Refer to otolaryngology if bleeding persists despite appropriate nasal packing 1, 2
• Consider surgical arterial ligation or endovascular embolization (97% success rate) if bleeding is not controlled by packing or cauterization 2
• Refer to dentistry/periodontology for persistent gingival bleeding requiring specialized intervention 5