Epistaxis in the setting of antithrombotic therapy: A comparison between factor Xa inhibitors, warfarin, and antiplatelet agents

Abstract

Objectives/Hypothesis To describe the characteristics and severity of epistaxis in patients taking factor Xa inhibitors novel anticoagulants. Study Design Retrospective cohort study. Methods A study of adult patients hospitalized due to spontaneous epistaxis under the treatment of warfarin, rivaroxaban, or apixaban between the years 2011 and 2017 was performed. A control group of patients under antiplatelet therapy (acetylsalicylic acid, clopidogrel) was included. The mean follow‐up periods in the warfarin, rivaroxaban, apixaban, and antiplatelet groups were 18, 14.5, 13.5, and 18.2 months, respectively. We compared demographics, location and severity of bleeding, treatment methods, and outcome between the groups. Results The study included 109 patients (35 under factor Xa inhibitors), the majority of whom presented with anterior epistaxis (68%). The antiplatelet group had more episodes of epistaxis prior to admission, and required endoscopic surgical control of bleeding more often, in comparison with anticoagulants (2.23 vs. 1.44, P < .05 and 23% vs. 6%, respectively, P < .05). Among anticoagulants, combined therapy (cauterization and packing) was required more frequently in the apixaban group compared to the rivaroxaban and warfarin groups (64% vs. 25% and 33%, respectively, P < .05). The rate of readmissions due to epistaxis, within 1 year of follow‐up was lower in the factor Xa inhibitor groups compared with the warfarin and antiplatelet groups (16% vs. 9% and 4%, respectively, P < .05). Cessation of factor Xa inhibitor therapy was effective and uneventful with no further epistaxis events. Conclusions Epistaxis under factor Xa inhibitors was effectively treated with no worse and perhaps even a better outcome when compared to other anticlotting medications. Level of Evidence: 4 Laryngoscope, 129:119–123, 2019

Frequency of epistaxis by months and daytime hours

“…In a study conducted by Purkey et al, it was found that the incidence of epistaxis was higher in the cold seasons (28). In the study conducted by Glikson et al, the frequency of epistaxis was found to be higher in the winter months (29). In our study, it was found that bleeding in all epistaxis sites was higher in the winter months and was statistically significant.…”

The Impact of Traditional Anticoagulants, Novel Anticoagulants, and Antiplatelets on Epistaxis

“…While there are some studies demonstrating fewer hospital admissions 9,10 and shorter hospital stays with NOACs compared to VKAs, other studies reported bleeding to be more severe with NOACs 11 . Furthermore, data on epistaxis outcomes in patients taking NOACs compared to patients taking antiplatelet medications is very limited 12 …”

Regarding epistaxis in the setting of antithrombotic therapy: A comparison between factor Xa inhibitors, warfarin, and antiplatelet agents

“…We read Glikson et al's report 1 with interest and would like to underscore some key points regarding the role of anticoagulation reversal in the management of patients hospitalized with epistaxis. Most notably, the study does not systematically report its use.…”

“…Lastly, the authors state that "[rivaroxaban and apixaban] have a short half-life time (7-14 hours) compared to warfarin, and withholding them can be very effective." 1 The elimination half-lives of apixaban and rivaroxaban in elderly patients are 15 hours and 12 hours, respectively. 3,4 As such, it would take at least 60 hours (approximately 5 half-lives) to eliminate 96% of the drug-unacceptably long in the setting of critical bleeding.…”