A systematic review of anti-thrombotic therapy in epistaxis

Abstract

There is limited guidance available to clinicians regarding the management of antithrombotic therapy during epistaxis, whilst there has been an increase in the use of anticoagulation and antiplatelet therapy. In addition, the introduction of direct oral anticoagulants (DOACs), such as dabigatran and rivaroxaban, over the last decade has significantly increased the complexity of managing the anticoagulated epistaxis patient. We undertook a systemic literature review investigating potential management strategies for each class of anti-thrombotic therapy during epistaxis. A PubMED and Cochrane Library search was performed on 10/03/16 using, but not limited to, the search terms epistaxis, nosebleed, nose bleeding, nasal haemorrhage, nasal bleeding AND each of the following search terms: antithrombotic, anticoagulant, antiplatelet, aspirin, clopidogrel, warfarin, dabigatran, rivaroxaban, apixaban and tranexamic acid. This yielded 3815 results, of which 29 were considered relevant. Other sources such as national and international guidelines related to the management of anti-thrombotics were also utilised. We present the findings related to the management of each class of anti-thrombotic therapy during epistaxis. Overall we found a lack of evidence regarding this topic and further high quality research is needed. This is an area growing in complexity and the support of colleagues in Haematology and Cardiology is increasingly important.

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

“…Epistaxis is a common disorder that may account for 33% of all otolaryngology emergency admissions . The majority of admissions are in older adults, with a median age at admission of 70 years . As life expectancy increases, the rate of chronic illnesses including prothrombotic conditions rises.…”

Epistaxis in anticoagulated patients: Fewer hospital admissions and shorter hospital stays on rivaroxaban compared to phenprocoumon

“…Epistaxis is a common reason for emergency department (ED) attendance, accounting for up to 1 in 200 ED visits in the United States . With 20,000 hospital admissions and 36 000 hospital bed days from 2014 to 2105 in the United Kingdom, epistaxis represents a relevant burden to a medical system . Antithrombotic therapy was previously found to be present in 60% of patients admitted to an ED with epistaxis .…”

“…With 20,000 hospital admissions and 36 000 hospital bed days from 2014 to 2105 in the United Kingdom, epistaxis represents a relevant burden to a medical system . Antithrombotic therapy was previously found to be present in 60% of patients admitted to an ED with epistaxis . Specifically, epistaxis under anticoagulant therapy with the vitamin K antagonist (VKA) warfarin is known to be associated with an increased hospital admission rate and length of hospital stay as well as more surgical interventions compared with patients without anticoagulant therapy …”

“…As such it seems likely that patients taking DOACs will become increasingly common in the ED. However, a recent review of epistaxis patients found a lack of studies including patients treated with DOAC and could not identify a direct comparison of patients under DOAC or VKAs . Only a few case reports about the management of patients with epistaxis on DOAC therapy exist .…”

Evidence-based and precision medicine two of a kind

“…In Rhinology, in the last few years, a number of systematic reviews (7)(8)(9)(10) , meta-analyses (11,12) and RCT's (13)(14)(15)(16)(17) have been published to help clinicians to guide their practice. This evidence has brought us a lot of good: we now know that it is not useful to treat simple acute rhinosinusitis patients with antibiotics (7) ,…”