Management of Nosebleeds on Eliquis (Apixaban)

Introduction to Management

The American Academy of Otolaryngology-Head and Neck Surgery recommends continuing anticoagulation and using first-line local treatments before considering medication withdrawal, except in life-threatening bleeding 1, 2

Apply firm, sustained compression to the lower third of the nose for 5-15 minutes without releasing pressure, which stops bleeding in 65-75% of cases 1, 2
Sit upright and lean the head slightly forward to prevent blood from entering the airway or stomach 3
Breathe through the mouth and spit out any blood rather than swallowing it 3
After compression, spray oxymetazoline or phenylephrine nasal spray and continue holding pressure for another 5 minutes 1, 3

Go to the emergency department immediately if bleeding continues despite 15-30 minutes of proper compression, or if experiencing lightheadedness, weakness, or difficulty breathing due to blood in the airway 3
Seek emergency care if there is severe blood loss, hemodynamic instability, or a hemoglobin drop ≥2 g/dL 3

Perform anterior rhinoscopy to identify the bleeding site after clot removal 2
Use nasal cautery or apply moisturizing/lubricating agents to the identified bleeding site 2
Use resorbable packing materials if packing becomes necessary, as these are safer for patients on anticoagulants 1, 2
Continue Eliquis unless bleeding is life-threatening 1, 2

Stop Eliquis immediately and provide local therapy/manual compression for major/life-threatening epistaxis 3
Provide supportive care and volume resuscitation 3
Consider reversal agents such as 4-factor prothrombin complex concentrate or andexanet alfa 1, 3

The physician who prescribed Eliquis must be involved in any decision about medication management 3
Nosebleeds are a known side effect of Eliquis, and patients taking anticoagulants are more likely to present with recurrent epistaxis 1
The thrombotic risk from stopping Eliquis typically outweighs the bleeding risk from minor epistaxis 1, 3

Contact the healthcare provider or go to the emergency department if experiencing fever over 101°F, vision changes, shortness of breath, swelling of the face, diffuse skin rash, or increasing pain 4

The American Academy of Otolaryngology-Head and Neck Surgery recommends applying firm, sustained compression to the soft lower third of the nose for a full 15 minutes without releasing pressure to check if bleeding has stopped, and breathing through the mouth and spitting out any blood rather than swallowing it, in patients on anticoagulants 5
After 15 minutes of compression, if bleeding slows but hasn't stopped, blowing the nose once to clear clots, then spraying oxymetazoline (Afrin) or phenylephrine 2 sprays into the bleeding nostril, and continuing to hold pressure for another 5-10 minutes after applying the vasoconstrictor, is recommended 5

For non-life-threatening epistaxis, the American Academy of Otolaryngology-Head and Neck Surgery recommends continuing both anticoagulants and using local hemostatic measures first, and if packing becomes necessary, using only resorbable/absorbable packing materials (such as Nasopore, Surgicel, or Floseal) in patients on anticoagulants and antiplatelets 6
Non-resorbable packing materials should be avoided in patients on dual antiplatelet/anticoagulant therapy, according to the American Academy of Otolaryngology-Head and Neck Surgery 6

The American Academy of Otolaryngology-Head and Neck Surgery recommends applying petroleum jelly or nasal saline gel to the nasal mucosa 2-3 times daily for at least one week to prevent recurrence, and avoiding nose blowing, strenuous activity, heavy lifting, or placing tissues/cotton in the nose for at least 7 days 5
Using a bedside humidifier to keep nasal mucosa moist is also recommended by the American Academy of Otolaryngology-Head and Neck Surgery 5

Patients requiring nasal packing, cauterization, or any invasive intervention should have documented follow-up within 30 days to assess for complications and recurrent bleeding, as recommended by the American Academy of Otolaryngology-Head and Neck Surgery 5, 6