How should I manage an elderly woman on apixaban (Eliquis) with persistent epistaxis for two days?

Management of Persistent Epistaxis in an Elderly Woman on Apixaban

Continue apixaban without interruption and aggressively pursue first-line local control measures before considering any anticoagulation modification, as withholding anticoagulation increases thrombotic risk which carries higher morbidity and mortality than the epistaxis itself. 1

Immediate Local Control Measures

First-Line Compression and Vasoconstriction

• Apply firm, sustained compression to the soft lower third of the nose for a full 10–15 minutes without intermittent checking—premature release is the most common cause of treatment failure 2, 1
• Position the patient seated with head tilted slightly forward to prevent blood from entering the airway or stomach 2
• Instruct her to breathe through her mouth and expectorate blood rather than swallow it 2, 1
• After compression, clean the nasal cavity of clots and apply topical vasoconstrictor (oxymetazoline or phenylephrine spray, 2 sprays into the bleeding nostril), which stops bleeding in 65–75% of emergency department cases 2, 1, 3
• Resume firm compression for an additional 5–10 minutes after applying the vasoconstrictor 2

If Bleeding Persists: Endoscopic Evaluation and Cautery

• Perform anterior rhinoscopy after clot removal to identify the bleeding source 2, 3
• If the source remains unclear or bleeding is difficult to control, proceed to nasal endoscopy, which localizes the bleeding site in 87–93% of cases 2, 3
• If a specific bleeding point is identified, anesthetize with topical lidocaine and cauterize only the active bleeding site—avoid bilateral simultaneous septal cautery as this markedly increases septal perforation risk 2, 1, 3

Nasal Packing (Only if Above Measures Fail)

• Proceed to nasal packing only when bleeding persists after 15–30 minutes of proper compression combined with vasoconstrictors 2, 1
• Use only resorbable/absorbable packing materials (Nasopore, Surgicel, or Floseal) in patients on anticoagulants to minimize trauma during removal 2, 1, 3
• Non-resorbable packing should be avoided in anticoagulated patients 2

Critical Anticoagulation Management Principle

Do not discontinue or reverse apixaban for recurrent epistaxis unless bleeding is life-threatening (massive hemorrhage requiring transfusion, hemodynamic instability, or airway compromise) 4, 1, 3. The American Academy of Otolaryngology-Head and Neck Surgery explicitly recommends initiating first-line local treatments prior to transfusion, reversal, or withdrawal of anticoagulation in the absence of life-threatening bleeding 1, 3.

Reversal Only for Life-Threatening Hemorrhage

• If life-threatening bleeding occurs with apixaban, the suggested reversal protocol is andexanet alfa (400 mg IV bolus over 15 minutes followed by 480 mg infusion over 2 hours for low dose, or 800 mg over 30 minutes followed by 960 mg over 2 hours for high dose) 4
• If andexanet alfa is unavailable, administer 2000 units of four-factor prothrombin complex concentrates 4
• Do not routinely use reversal agents for non-life-threatening epistaxis—the risks of thrombotic events and blood product exposure outweigh benefits 1

Prevention of Recurrence: The Cornerstone Strategy

Aggressive nasal mucosal moisturization is the cornerstone of preventing recurrent epistaxis in anticoagulated patients 1:

• Apply petroleum jelly to the anterior nasal septum 1–3 times daily, particularly before bedtime 2, 1, 3
• Use regular saline nasal sprays throughout the day to maintain mucosal moisture 2, 1, 3
• Consider bedside humidification during sleep, especially in dry climates or winter months 2, 1

When to Escalate Care

Indications for ENT Referral

• Persistent bleeding despite appropriate nasal packing 2, 3
• Recurrent epistaxis despite correct local treatment and preventive measures 2, 3
• Evaluation for surgical arterial ligation (endoscopic sphenopalatine artery ligation has 97% success rate) or endovascular embolization (80% success rate) when bleeding is not controlled by packing or cauterization 2, 3

Red-Flag Signs Requiring Immediate Escalation

• Active bleeding despite correctly placed packing 2
• Hemodynamic instability (tachycardia, hypotension) 2
• Fever >38.3°C (101°F) 2
• New visual disturbances 2
• Dizziness or other signs of significant blood loss 2

Special Considerations for Elderly Patients

• Elderly patients (≥75 years) should be triaged urgently because age-related anatomic changes increase the likelihood of posterior bleeding sources and complications 2
• Obtain baseline blood pressure, as approximately 33% of epistaxis patients have undiagnosed hypertension 2
• Document all medications, as elderly patients often have multiple comorbidities and polypharmacy that may complicate management 2, 5

Common Pitfalls to Avoid

• Do not routinely discontinue anticoagulation to see if bleeding stops—this practice is not evidence-based and significantly increases stroke risk 1
• Do not administer fresh frozen plasma, platelet transfusions, or reversal agents for non-life-threatening epistaxis—these expose patients to unnecessary risks without proven benefit 1
• Do not underestimate simple moisturization measures—these are highly effective in preventing recurrence and should be the primary preventive strategy 1
• Do not perform bilateral cautery simultaneously—this increases septal perforation risk 2, 1, 3

Follow-Up and Documentation

• Document the outcome of intervention within 30 days to assess treatment effectiveness 1, 3
• Educate the patient about preventive measures (nasal moisturization), proper home treatment technique, and indications to seek emergency care 1, 3
• Assess for hereditary hemorrhagic telangiectasia if bilateral recurrent bleeding or visible nasal/oral telangiectasias are present, as this may require specialist referral and alternative management strategies 2, 1, 3