Management of Recurrent Epistaxis in Patients on Anticoagulation Therapy

Initial Management

The American Academy of Otolaryngology-Head and Neck Surgery recommends applying firm sustained compression to the lower third of the nose for 5-15 minutes with the patient seated and head tilted slightly forward 1
For patients with recurrent epistaxis, the American Academy of Otolaryngology-Head and Neck Surgery suggests using resorbable packing materials if packing becomes necessary due to their anticoagulant use 1
The patient should breathe through the mouth and spit out blood rather than swallowing it, as recommended by the American Academy of Otolaryngology-Head and Neck Surgery 2
After compression, the nasal cavity should be cleaned of clots and a topical vasoconstrictor (oxymetazoline or phenylephrine) should be applied, as suggested by the American Academy of Otolaryngology-Head and Neck Surgery 2

The American Academy of Otolaryngology-Head and Neck Surgery recommends documenting factors that increase bleeding frequency/severity, particularly the use of anticoagulants like apixaban 1
In the absence of life-threatening bleeding, the American Academy of Otolaryngology-Head and Neck Surgery suggests continuing anticoagulation therapy and initiating first-line treatments rather than reversing or withdrawing anticoagulation 1
Moisturizing or lubricating agents (petroleum jelly) should be applied to the nasal mucosa to prevent recurrence, as recommended by the American Academy of Otolaryngology-Head and Neck Surgery 2
Regular use of saline nasal sprays is recommended to keep the nasal mucosa moist, as suggested by the American Academy of Otolaryngology-Head and Neck Surgery 2

The American Academy of Otolaryngology-Head and Neck Surgery recommends performing nasal endoscopy to identify the bleeding site and guide further management in patients with recurrent bleeding 1
Nasal cautery should be considered if a specific bleeding site is identified, ensuring proper anesthesia and restricting cautery only to the active bleeding site, as suggested by the American Academy of Otolaryngology-Head and Neck Surgery 1
The patient should be educated about preventive measures, home treatment, and indications to seek additional medical care, as recommended by the American Academy of Otolaryngology-Head and Neck Surgery 1

If bleeding persists despite initial measures, referral to an otolaryngologist is recommended, as suggested by the American Academy of Otolaryngology-Head and Neck Surgery 2
Evaluation for surgical arterial ligation or endovascular embolization should be considered if bleeding is not controlled by packing or nasal cauterization, as recommended by the American Academy of Otolaryngology-Head and Neck Surgery 1
Assessment for possible hereditary hemorrhagic telangiectasia is recommended if the patient has recurrent bilateral nosebleeds, as suggested by the American Academy of Otolaryngology-Head and Neck Surgery 1

The outcome of intervention should be documented within 30 days, as recommended by the American Academy of Otolaryngology-Head and Neck Surgery 1
If nasal packing was used, the patient should be educated about care and signs/symptoms that would warrant reassessment, as suggested by the American Academy of Otolaryngology-Head and Neck Surgery 1