What is the management for a patient with epistaxis on Xarelto (rivaroxaban) for atrial fibrillation with elevated prothrombin time and international normalized ratio (INR) of 2.1?

From the Guidelines

For a patient with a nosebleed who is taking Xarelto (rivaroxaban) for atrial fibrillation with a PT of 23.4 and INR of 2.1, immediate management should focus on controlling the bleeding while addressing the anticoagulation status. The patient's INR of 2.1 is not directly relevant to Xarelto, as it is a direct oral anticoagulant (DOAC) that does not require INR monitoring 1.

Initial Management

• Apply direct pressure to the anterior portion of the nose by pinching the soft part of the nostrils together continuously for 10-15 minutes while the patient sits upright and leans slightly forward.
• Apply a cold compress to the bridge of the nose.
• If bleeding persists after 20 minutes of pressure, seek emergency care.

Anticoagulation Management

For persistent bleeding, temporary discontinuation of Xarelto may be necessary after consultation with the prescribing physician, weighing the risk of thromboembolism against continued bleeding 1.

• Xarelto has a relatively short half-life (5-9 hours), so hemostasis should improve within 24 hours of discontinuation.
• For severe bleeding, andexanet alfa (a specific reversal agent) may be considered in a hospital setting, as it is the recommended reversal agent for rivaroxaban 1.

Reversal Agents

The use of reversal agents such as andexanet alfa should be guided by the timing of the last dose of Xarelto and the severity of the bleeding 1.

• If the last dose of Xarelto was taken <8 hours prior, or the timing is unknown, high-dose andexanet alfa may be considered.
• The patient should discuss with their physician whether to resume Xarelto or consider alternative anticoagulation strategies once the bleeding is controlled.

From the Research

Patient Profile

• The patient is experiencing a nose bleed while on Xaralto (rivaroxaban) for atrial fibrillation.
• The patient's PROTIME is 23.4 and INR is 2.1.

Anticoagulation Management

• According to 2, anticoagulation with antivitamin K (AVK) is effective for primary and secondary prevention of thromboembolic events, but questions persist about the risks and management of over-anticoagulation.
• The study suggests that vitamin K administration can rapidly lower the INR into a safe range to reduce the risk of major bleeding.
• However, 3 found that withholding warfarin or giving vitamin K treatment was ineffective at reducing the INR within 24 hours in patients with INR higher than 9.

Bleeding Risks

• 3 reported that an INR higher than 9 is associated with a high risk of bleeding, and factors such as older age, renal failure, and alcohol use are associated with bleeding.
• 4 found that there were no significant differences in terms of age, sex, vital signs, bloodwork, or location of bleeding between patients treated with direct oral anticoagulants and vitamin K antagonists.

Treatment Options

• 5 suggests that dissolvable intranasal haemostatic agents may be effective in managing acute epistaxis, but more data are required before recommendations can be made regarding management in patients on anticoagulants.
• 6 recommends that transfusion of plasma to reverse an elevated INR in the ICU should be discouraged, as it is either avoidable by the use of vitamin K or inappropriate in the case of liver disease or an anti-Xa DOAC.

Considerations for Xaralto

• 4 found that there was no evidence to suggest that epistaxis is more severe or requires more invasive therapy in patients given direct oral anticoagulants, such as Xaralto.
• However, the management of epistaxis in patients on Xaralto may require careful consideration of the patient's individual risk factors and the potential benefits and risks of different treatment options.