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Management of epistaxis in patients on novel oral anticoagulation therapy

Published online by Cambridge University Press:  13 April 2020

J P K Ho ,
N Bari  and
F Riffat
J P K Ho*
Affiliation:
Department of Otolaryngology Head and Neck Surgery, Westmead Hospital, Australia Sydney Medical School, University of Sydney, Camperdown, Australia
N Bari
Affiliation:
Department of Emergency Medicine, Blacktown Hospital, Australia
F Riffat
Affiliation:
Department of Otolaryngology Head and Neck Surgery, Westmead Hospital, Australia Sydney Medical School, University of Sydney, Camperdown, Australia
*
Author for correspondence: Dr Joyce Ho, Department of Otolaryngology Head and Neck Surgery, Westmead Hospital, Hawkesbury Road, Westmead, New South Wales, Australia 2145 E-mail: joycepkho@gmail.com Fax: +61 2 8890 9852
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Abstract

Background

Individuals on anticoagulation therapy are at increased risk of bleeding, including epistaxis. There is a lack of available reversal agents for novel oral anticoagulation therapy.

Objective

This paper reviews the current literature on epistaxis in the context of novel oral anticoagulation use, in order to recommend guidelines on management.

Method

A comprehensive search of published literature was conducted to identify all relevant articles published up to April 2019.

Results

Patients on oral anticoagulation therapy are over-represented in individuals with epistaxis. Those on novel oral anticoagulation therapy were more likely to relapse compared to patients on classic oral anticoagulants or non-anticoagulated patients. Idarucizumab is an effective antidote for bleeding associated with dabigatran use. Recommendations for epistaxis management in patients on novel oral anticoagulation therapy are outlined.

Conclusion

Clinicians need to be aware of the potential severity of epistaxis and the increased likelihood of recurrence. High-quality studies are required to determine the efficacy and safety of andexanet alfa and ciraparantag, as well as non-specific reversal agents.

Keywords

AnticoagulantsDabigatranEpistaxisFirst AidRivaroxaban
Type
Main Articles
Information
The Journal of Laryngology & Otology , Volume 134 , Issue 4 , April 2020 , pp. 316 - 322
Copyright
Copyright © The Author(s), 2020. Published by Cambridge University Press

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Footnotes

Dr Joyce Ho takes responsibility for the integrity of the content of the paper

References

Viehweg, TL, Roberson, JB, Hudson, J. Epistaxis: diagnosis and treatment. J Oral Maxillofac Surg 2006;64:511–18CrossRefGoogle ScholarPubMed
Douglas, R, Wormald, P-J. Update on epistaxis. Curr Opin Otolaryngol Head Neck Surg 2007;15:180–3CrossRefGoogle ScholarPubMed
Chen, BC, Viny, AD, Garlich, FM, Basciano, P, Howland, MA, Smith, SW et al. Hemorrhagic complications associated with dabigatran use. Clin Toxicol 2012;50:854–7CrossRefGoogle ScholarPubMed
Ganetsky, M, Babu, KM, Salhanick, SD, Brown, RS, Boyer, EW. Dabigatran: review of pharmacology and management of bleeding complications of this novel oral anticoagulant. J Med Toxicol 2011;7:281–7CrossRefGoogle ScholarPubMed
Buchheit, J, Reddy, P, Connors, JM. Idarucizumab (Praxbind) formulary review. Crit Pathw Cardiol 2016;15:77–81CrossRefGoogle ScholarPubMed
Buchberger, AMS, Baumann, A, Johnson, F, Peters, N, Piontek, G, Storck, K et al. The role of oral anticoagulants in epistaxis. Eur Arch Otorhinolaryngol 2018;275:2035–43CrossRefGoogle ScholarPubMed
Callejo, FJG, Martínez, CB, González, JC, Beneyto, PM, Sanz, MM, Algarra, JM. Epistaxis and dabigatran, a new non-vitamin K antagonist oral anticoagulant. Acta Otolaryngol 2014;65:346–54Google Scholar
L'Huillier, V, Badet, C, Tavernier, L. Epistaxis complicating treatment by anti-vitamin K and new oral anticoagulants. Eur Ann Otorhinolaryngol Head Neck Dis 2018;135:231–5CrossRefGoogle ScholarPubMed
Hylek, EM, Held, C, Alexander, JH, Lopes, RD, De Caterina, R, Wojdyla, DM et al. Major bleeding in patients with atrial fibrillation receiving apixaban or warfarin: the ARISTOTLE Trial (Apixaban for Reduction in Stroke and Other Thromboembolic Events in Atrial Fibrillation): predictors, characteristics, and clinical outcomes. J Am Coll Cardiol 2014;63:2141–7CrossRefGoogle Scholar
Connolly, SJ, Ezekowitz, MD, Yusuf, S, Eikelboom, J, Oldgren, J, Parekh, A et al. Dabigatran versus warfarin in patients with atrial fibrillation. N Engl J Med 2009;361:1139–51CrossRefGoogle ScholarPubMed
Spielmann, P, Barnes, M, White, P. Controversies in the specialist management of adult epistaxis: an evidence-based review. Clin Otolaryngol 2012;37:382–9CrossRefGoogle Scholar
Thaha, M, Nilssen, E, Holland, S, Love, G, White, P. Routine coagulation screening in the management of emergency admission for epistaxis – is it necessary? J Laryngol Otol 2000;114:38–40CrossRefGoogle ScholarPubMed
Sandoval, C, Dong, S, Visintainer, P, Ozkaynak, MF, Jayabose, S. Clinical and laboratory features of 178 children with recurrent epistaxis. J Pediatr Hematol Oncol 2002;24:47–9CrossRefGoogle ScholarPubMed
Levy, JH, Douketis, J, Weitz, JI. Reversal agents for non-vitamin K antagonist oral anticoagulants. Nat Rev Cardiol 2018;15:273–81CrossRefGoogle ScholarPubMed
McGarry, G, Moulton, C. The first aid management of epistaxis by accident and emergency department staff. Emerg Med J 1993;10:298–300CrossRefGoogle ScholarPubMed
Strachan, D, England, J. First-aid treatment of epistaxis--confirmation of widespread ignorance. Postgrad Med J 1998;74:113–14CrossRefGoogle ScholarPubMed
Lavy, J. Epistaxis in anticoagulated patients: educating an at-risk population. Br J Haematol 1996;95:195–7CrossRefGoogle ScholarPubMed
Barnes, M, Spielmann, P, White, P. Epistaxis: a contemporary evidence based approach. Otolaryngol Clin North Am 2012;45:1005–17CrossRefGoogle ScholarPubMed
Schiele, F, van Ryn, J, Newsome, C, Sepulveda, E, Park, J, Nar, H et al. A specific antidote for dabigatran: functional and structural characterization. Blood 2013;121:3554–62CrossRefGoogle ScholarPubMed
Siegal, DM, Curnutte, JT, Connolly, SJ, Lu, G, Conley, PB, Wiens, BL et al. Andexanet alfa for the reversal of factor Xa inhibitor activity. N Engl J Med 2015;373:2413–24CrossRefGoogle ScholarPubMed
Ansell, JE. Universal, class-specific and drug-specific reversal agents for the new oral anticoagulants. J Thromb Thrombolysis 2016;41:248–52CrossRefGoogle ScholarPubMed
Pollack, CV Jr, Reilly, PA, Van Ryn, J, Eikelboom, JW, Glund, S, Bernstein, RA et al. Idarucizumab for dabigatran reversal – full cohort analysis. N Engl J Med 2017;377:431–41CrossRefGoogle ScholarPubMed
Ansell, JE, Bakhru, SH, Laulicht, BE, Steiner, SS, Grosso, MA, Brown, K et al. Single-dose ciraparantag safely and completely reverses anticoagulant effects of edoxaban. Thromb Haemost 2017;117:238–45Google ScholarPubMed
Pollack, CV Jr, Reilly, PA, Bernstein, R, Dubiel, R, Eikelboom, J, Glund, S et al. Design and rationale for RE-VERSE AD: a phase 3 study of idarucizumab, a specific reversal agent for dabigatran. Thromb Haemost 2015;114:198–205Google ScholarPubMed
Glund, S, Moschetti, V, Norris, S, Stangier, J, Schmohl, M, van Ryn, J et al. A randomised study in healthy volunteers to investigate the safety, tolerability and pharmacokinetics of idarucizumab, a specific antidote to dabigatran. Thromb Haemost 2015;113:943–51Google ScholarPubMed
Connolly, SJ, Crowther, M, Eikelboom, JW, Gibson, CM, Curnutte, JT, Lawrence, JH et al. Full study report of andexanet alfa for bleeding associated with factor Xa inhibitors. N Engl J Med 2019;380:1326–35CrossRefGoogle ScholarPubMed
Raval, AN, Cigarroa, JE, Chung, MK, Diaz-Sandoval, LJ, Diercks, D, Piccini, JP et al. Management of patients on non-vitamin K antagonist oral anticoagulants in the acute care and periprocedural setting: a scientific statement from the American Heart Association. Circulation 2017;135:e604–33CrossRefGoogle ScholarPubMed
Eerenberg, ES, Kamphuisen, PW, Sijpkens, MK, Meijers, JC, Buller, HR, Levi, M. Reversal of rivaroxaban and dabigatran by prothrombin complex concentrate. Circulation 2011;124:1573–9CrossRefGoogle ScholarPubMed
Marlu, R, Hodaj, E, Paris, A, Albaladejo, P, Crackowski, JL, Pernod, G. Effect of non-specific reversal agents on anticoagulant activity of dabigatran and rivaroxaban. Thromb Haemost 2012;108:217–24CrossRefGoogle ScholarPubMed
Nagalla, S, Thomson, L, Oppong, Y, Bachman, B, Chervoneva, I, Kraft, W. Reversibility of apixaban anticoagulation with a four-factor prothrombin complex concentrate in healthy volunteers. Clin Transl Sci 2016;9:176–80CrossRefGoogle ScholarPubMed
Mariat, C, Alamartine, E, Masson, I, Maillard, N, Claisse, G, Delavenne, X. Venovenous haemodiafiltration for the management of dabigatran overdose in intensive care unit. Clin Kidney J 2015;8:199–201Google Scholar
Chen, BC, Sheth, NR, Dadzie, KA, Basciano, P, Howland, MA, Smith, SW et al. Hemodialysis for the treatment of pulmonary hemorrhage from dabigatran overdose. Am J Kidney Dis 2013;62:591–4CrossRefGoogle ScholarPubMed
Di Fusco, SA, Lucà, F, Benvenuto, M, Iorio, A, Fiscella, D, D'Ascenzo, F et al. Major bleeding with old and novel oral anticoagulants: how to manage it. Focus on reversal agents. Int J Cardiol 2018;268:75–9Google Scholar