warfarin and Epistaxis

The management of epistaxis requires an understanding of haematological factors that may complicate its treatment. This systematic review includes six distinct reviews examining the evidence supporting epistaxis-specific management strategies relating to warfarin, direct oral anticoagulants, heparin, antiplatelet agents, tranexamic acid and transfusion.. A systematic review of the literature was performed using a standardised methodology and search strategy.. Limited numbers of articles were identified in each systematic review, with level 1 evidence only regarding the use of tranexamic acid. No studies met the inclusion criteria within the heparin, direct oral anticoagulants or transfusion systematic reviews. Many studies were limited by small sample sizes and significant risk of bias.. The management of major bleeding and transfusion practice is well documented in national guidance from multiple sources. The guidelines include advice on anticoagulants, antiplatelet agents and tranexamic acid. In the absence of more specific evidence, these guidelines should be applied in the management of epistaxis.

Topics: Adult; Anticoagulants; Blood Transfusion; Epistaxis; Evidence-Based Medicine; Guideline Adherence; Heparin; Humans; International Normalized Ratio; Length of Stay; Platelet Aggregation Inhibitors; Tranexamic Acid; Treatment Outcome; Warfarin

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.

Topics: Anticoagulants; Antifibrinolytic Agents; Aspirin; Clopidogrel; Dabigatran; Disease Management; Epistaxis; Humans; Platelet Aggregation Inhibitors; Pyrazoles; Pyridones; Risk Assessment; Rivaroxaban; Ticlopidine; Tranexamic Acid; Warfarin

Most cases of epistaxis are due to simple causes and are easily treated on an out-patient basis. However, there are some cases where the origin of bleeding is not obvious or arises from an unusual pathological source. The authors describe a case of epistaxis due to a mass in the maxillary antrum that when biopsied showed the histological appearances of a haemophilic pseudotumour. The patient was anticoagulated on warfarin for a cardiac valve replacement and this was thought to be the cause of the ongoing haemorrhage necessary for development of the pseudotumour. Even in haemophiliacs, pseudotumours are rare and we believe this case is unique in that the patient is a non-haemophiliac. The epistaxis was eventually controlled by external beam radiotherapy to the pseudotumour. The management of this case is outlined as well as a review of the literature on haemophilic pseudotumour.

Topics: Aged; Anticoagulants; Cysts; Epistaxis; Hemophilia A; Humans; Male; Paranasal Sinus Diseases; Paranasal Sinuses; Tomography, X-Ray Computed; Warfarin

To evaluate the impact of a pharmacist-led warfarin patient self-management program on quality of life and anticoagulation control compared with management in a physician-led specialized anticoagulation clinic.. Prospective, randomized, controlled, open-label trial.. Tertiary care academic medical center.. A total of 114 patients aged 18-75 years who were followed at a specialized anticoagulation clinic, had received warfarin for at least 6 months, and were expected to continue warfarin for a minimum of 4 months.. All patients attended an educational session on anticoagulation provided by a pharmacist. Patients randomized to the self-management group (58 patients) also received practical training to use the CoaguChek XS device and a self-management dosing algorithm. Patients in the control group (56 patients) continued to undergo standard management at the anticoagulation clinic.. Patients completed a validated quality-of-life questionnaire and the validated Oral Anticoagulation Knowledge test at the beginning and end of the study. The quality of anticoagulation control was evaluated by using the time spent in therapeutic range. After 4 months of follow-up, a significant improvement in the self-management group was observed compared with the control group in four of the five quality-of-life topics (p<0.05). Improvements in knowledge were observed in both groups after the training session and persisted after 4 months (p<0.05 for all). The time spent in the therapeutic range (80.0% in the self-management group vs 75% in the control group, p=0.79) and in the extended therapeutic range ([target international normalized ratio ± 0.3] 93.2% in the self-management group vs 91.1% in the control group, p=0.30) were similar between groups.. A self-management warfarin program led by pharmacists resulted in significant improvement in the quality of life of patients receiving warfarin therapy as well as a reduction in the time required for anticoagulation monitoring, while maintaining a level of anticoagulation control similar to a high-quality specialized anticoagulation clinic.

Topics: Academic Medical Centers; Adolescent; Adult; Aged; Anticoagulants; Epistaxis; Female; Follow-Up Studies; Hospitals, Special; Humans; International Normalized Ratio; Male; Middle Aged; Outpatient Clinics, Hospital; Patient Education as Topic; Pharmacists; Quality of Life; Quebec; Self Administration; Self Care; Warfarin; Workforce; Young Adult

The object of this study was to determine whether warfarin could be safely continued in patients with epistaxis if the International Normalized Ratio (INR) was within the suggested therapeutic range. Twenty patients on warfarin treatment were compared with controls, matched for age and sex. Local measures for the control of epistaxis were undertaken appropriately in all the patients. In the warfarin group 17 patients (85%) did not discontinue warfarin as the INR was within the suggested range. There were no additional bleeding complications or failure of epistaxis control due to continuation of warfarin. There was no significant difference in the mean hospital stay between the warfarin and non-warfarin groups. It is concluded that warfarin can be continued safely in patients with epistaxis, in appropriate circumstances, and that the policy of stopping warfarin routinely in all patients with epistaxis should be reconsidered.

Topics: Aged; Anticoagulants; Epistaxis; Female; Humans; Length of Stay; Male; Prospective Studies; Time Factors; Warfarin

Patients anticoagulated with warfarin form a small proportion of those admitted with epistaxis annually to ENT units. The authors formed the impression that such patients spend longer in hospital and have more complicated management than controls. A prospective age and sex matched controlled study of 20 consecutive patients admitted with epistaxis whilst anticoagulated was performed. This showed that these patients spent significantly longer in hospital than controls, with an additional expense in the study period of 10,500 pounds for inpatient bed nights alone. The management of these patients is more complicated and there is a subgroup of poorly controlled patients who present most of the problems. A potential solution is to improve community warfarin control and to involve general practitioners and haematologists in the re-establishment of warfarin following admission for epistaxis.

Topics: Aged; Case-Control Studies; Epistaxis; Female; Humans; Length of Stay; Male; Middle Aged; Prospective Studies; Prothrombin Time; Warfarin

Epistaxis represents a massive burden upon NHS resources. Despite being an extremely common reason for emergency ENT admissions, there remains significant variation in its management. Although the evidence base is continually growing, there appears to be a lack of guidance towards managing anti-coagulants and anti-platelet medications and identifying patient-specific outcomes in this setting. Epistaxis has long been associated with a multitude of risk factors but none have shown consistent, direct correlation.. We aimed to identify if the use of anti-thrombotic medication was associated with a longer length of hospital admission or conferred a higher requirement for nasal packing, re-packing, surgery or re-admission. We conducted a retrospective analysis of 100 consecutive adult patients admitted over a 6-month period. Statistical analysis was conducted using SPSS software.. Sixty-five percent of patients were taking anti-thrombotic medication. The variability of admission INR values in those taking warfarin did not relate with any outcome measure. There was no statistical difference between patients taking anti-thrombotic medication and those who do not, with regards to our primary outcome measures. Re-admission rates within 28 days were found to be 13%, with anti-thrombotic medication use and pre-existing cardiovascular disease recognised as commonly encountered risk factors. Three percent of patients required surgical intervention. Eight percent of patients required re-packing, with a Rapid Rhino chosen in all instances.. The use of anti-thrombotic medication is not associated with increased morbidity or increased rate of complications. Anti-thrombotic usage and more than one medical co-morbidity increase the risk of re-admission within 28 days.

Topics: Adult; Epistaxis; Humans; Inpatients; Retrospective Studies; Thrombosis; Warfarin

Although epistaxis is one of the most common side effects of oral anticoagulation, it is unclear whether epistaxis rates vary between different oral anticoagulants (OAC).. To compare rates of clinically relevant epistaxis between OAC.. Epistaxis event rates were compared between new users of apixaban, dabigatran, rivaroxaban, and warfarin in a nationwide population-based cohort study over a 5-year study period, 2014-2019. Data was collected from the Icelandic Medicine Registry and the five major hospitals in Iceland. Inverse probability weighting (IPW) was used to yield balanced baseline characteristics, and epistaxis rates were compared using Kaplan-Meier survival estimates and Cox regression.. During the study period, 2098 patients received apixaban, 474 dabigatran, 3106 rivaroxaban, and 1403 warfarin. In total, 93 patients presented with clinically relevant epistaxis, including 11 (12%) major epistaxis events and one fatal epistaxis episode. Furthermore, seven patients (9%) with non-major epistaxis later presented with major bleeding during the follow-up period. Warfarin use was associated with higher rates of epistaxis compared to apixaban (2.2 events per 100-person years (events/100-py) vs. 0.6 events/100-py, hazard ratio [HR] 4.22, 95% confidence interval [CI] 2.08-8.59, p < 0.001), rivaroxaban (2.2 events/100-py vs. 1.0 events/100-py, HR 2.26, 95% CI 1.28-4.01, p = 0.005), and dabigatran (2.2 events/100-py vs. no events, HR n/a, p < 0.001).. Warfarin treatment was associated with higher rates of clinically relevant epistaxis compared to direct oral anticoagulants.

Topics: Administration, Oral; Anticoagulants; Atrial Fibrillation; Cohort Studies; Dabigatran; Epistaxis; Humans; Propensity Score; Pyridones; Retrospective Studies; Rivaroxaban; Stroke; Warfarin

Anticoagulated patients are often seen unnecessarily in the emergency department (ED) for epistaxis, leading to increased healthcare costs. Patients are often unaware of preventative and management techniques for handling epistaxis in the home.. In 2016, the Michigan Anticoagulation Quality Improvement Initiative (MAQI. Of the 4473 patients included, 2634 (58.9%) initiated warfarin in the pre-implementation phase and 1839 (41.1%) initiated warfarin in the post-implementation phase. The post-implementation cohort had a lower overall epistaxis rate (13.4 vs 10.4 per 100 patient-year, pre- vs. post-implementation; p = 0.029), a lower epistaxis-related ED visit rate (5.6 vs. 3.1 per 100 patient-year; p = 0.003), and a lower proportion of nosebleeds that led to an ED visit (42% vs. 30%; p = 0.032). After controlling for antiplatelet use, renal disease, and time in therapeutic range, both cohorts were equally likely to have nosebleeds (RR 0.77, 95% CI: 0.58-1.02); however, the post-implementation cohort was less likely to visit the ED for epistaxis (RR 0.52, 95% CI: 0.32-0.84).. An epistaxis education program was associated with a reduction in epistaxis-related ED visits among warfarin-treated patients.

Topics: Emergency Service, Hospital; Epistaxis; Health Care Costs; Humans; Quality Improvement; Retrospective Studies; Warfarin

Anticoagulant and antiplatelet medications (ACAP) are known to be associated with an increased risk for epistaxis. There are conflicting results regarding the impact of Novel Oral Anticoagulants (NOAC) on epistaxis and its severity.. Retrospective chart review of patients who were admitted to the ED in our tertiary level hospital with a diagnosis of epistaxis during the years 2012 to 2018.. Retrospective analysis of patients presenting to tertiary level emergency otolaryngological care during the years 2012 to 2018. The impact of various ACAP medications on epistaxis severity, hospital admission, and recurrence was analyzed.. A total of 470 patients were identified. Two hundred and twenty-nine patients (49%), were not on any anticoagulant/antiplatelet (ACAP) medications (controls) and 241 patients (51%) were taking at least one ACAP medication (ACAP group). Patients in the ACAP group were at a higher risk for severe epistaxis (OR = 1.8, P < .05) and were more likely to be hospitalized (OR = 2.17, P < .05). Surprisingly, the risk for recurrence was similar in the ACAP and control groups (15%, P > .05). Compared to controls, Warfarin and Enoxaparin increased the overall risk for severe epistaxis (OR = 4.4, P < .05) and for hospital admission (OR = 2.1, P < .05). Specifically, an increased risk for posterior tamponade (OR = 19, P < .001), significant blood loss (OR = 4.4, P = .032), and blood transfusion (OR = 4.7, P = .007) were identified as well. Interestingly, NOACs were not associated with increased risk for severe epistaxis, hospital admission, tamponade, and significant blood loss or blood transfusion compared to controls.. Compared to older generation anticoagulants and antiplatelet medications, NOACs demonstrated an improved safety profile, in terms of epistaxis severity, need for hospital admission and outcomes. These results may suggest a more conservative approach and less hospitalization when treating epistaxis in patients receiving NOACs.. 4 Laryngoscope, 131:1946-1951, 2021.

Topics: Administration, Oral; Adult; Aged; Aged, 80 and over; Anticoagulants; Case-Control Studies; Enoxaparin; Epistaxis; Factor Xa Inhibitors; Female; Hospitalization; Humans; Male; Middle Aged; Outcome Assessment, Health Care; Platelet Aggregation Inhibitors; Recurrence; Retrospective Studies; Safety; Severity of Illness Index; Warfarin

Epistaxis is a common presenting complaint in the emergency department. Proper technique to control the bleeding is essential. Active bleeding on an anticoagulant requires special consideration. Blood products and coagulopathy reversal are an important part of the resuscitation of an unstable bleeding patient on warfarin.. This resource was created to simulate a high-acuity and moderate-frequency event seen in emergency departments and on hospital wards. The target audience included emergency department residents, internal medicine residents, and advanced practice providers. The scenario detailed the case of an 82-year-old male on Coumadin who presented with epistaxis. A mannequin equipped with an epistaxis task trainer in which rate of bleeding could be controlled was required. The case was complicated by a choking episode on attempted nasal packing. It also involved warfarin coagulopathy requiring blood products and warfarin reversal. The simulation may be performed in a simulation lab or in situ in the emergency department, intensive care unit, or medical floor. Critical actions include addressing epistaxis with packing, recognizing blood-loss anemia related to warfarin coagulopathy, and recognizing and managing airway obstruction.. Approximately 35 learners completed this module in five separate sessions. Written evaluation from learners showed that 95% felt the simulation scenario and debriefing were effective.. Simulation is an ideal teaching tool for this life-threatening presentation. Learners can demonstrate proper technique and management of this difficult case.

Topics: Adult; Aged, 80 and over; Anticoagulants; Emergency Service, Hospital; Epistaxis; Humans; Male; Manikins; Warfarin

Hereditary hemorrhagic telangiectasia (HHT) is a rare vascular dysplasia resulting in visceral arteriovenous malformations and smaller mucocutaneous telangiectasia. Most patients experience recurrent nosebleeds and become anemic without iron supplementation. However, thousands may require anticoagulation for conditions such as venous thromboembolism and/or atrial fibrillation. Over decades, tolerance data has been published for almost 200 HHT-affected users of warfarin and heparins, but there are no published data for the newer direct oral anticoagulants (DOACs) in HHT.. To provide such data, a retrospective audit was conducted across the eight HHT centres of the European Reference Network for Rare Multisystemic Vascular Diseases (VASCERN), in Denmark, France, Germany, Italy, the Netherlands and the UK.. Although HHT Centres had not specifically recommended the use of DOACs, 32 treatment episodes had been initiated by other clinicians in 28 patients reviewed at the Centres, at median age 65 years (range 30-84). Indications were for atrial fibrillation (16 treatment episodes) and venous thromboembolism (16 episodes). The 32 treatment episodes used Apixaban (n = 15), Rivaroxaban (n = 14), and Dabigatran (n = 3). HHT nosebleeds increased in severity in 24/32 treatment episodes (75%), leading to treatment discontinuation in 11 (34.4%). Treatment discontinuation was required for 4/15 (26.7%) Apixaban episodes and 7/14 (50%) Rivaroxaban episodes. By a 4 point scale of increasing severity, there was a trend for Rivaroxaban to be associated with a greater bleeding risk both including and excluding patients who had used more than one agent (age-adjusted coefficients 0.61 (95% confidence intervals 0.11, 1.20) and 0.74 (95% confidence intervals 0.12, 1.36) respectively. Associations were maintained after adjustment for gender and treatment indication. Extreme hemorrhagic responses, worse than anything experienced previously, with individual nosebleeds lasting hours requiring hospital admissions, blood transfusions and in all cases treatment discontinuation, occurred in 5/14 (35.7%) Rivaroxaban episodes compared to 3/15 (20%) Apixaban episodes and published rates of ~ 5% for warfarin and heparin.. Currently, conventional heparin and warfarin remain first choice anticoagulants in HHT. If newer anticoagulants are considered, although study numbers are small, at this stage Apixaban appears to be associated with lesser bleeding risk than Rivaroxaban.

Topics: Administration, Oral; Aged; Aged, 80 and over; Anticoagulants; Atrial Fibrillation; Dabigatran; Epistaxis; Female; Humans; Male; Middle Aged; Pulmonary Embolism; Pyrazoles; Pyridones; Retrospective Studies; Rivaroxaban; Telangiectasia, Hereditary Hemorrhagic; Venous Thromboembolism; Warfarin

Epistaxis is one of the more common reasons for emergency room visits. The main risk factor for epistaxis is anticoagulant therapy. Until recently, the main culprit was oral intake of a vitamin K antagonist, such as warfarin, which has a number of side effects. Even more recently, several direct oral anticoagulants, rivaroxaban and dabigatran, have been approved for use. We investigated the possible differences between treatment of epistaxis with direct oral anticoagulants and vitamin K antagonists.. We conducted a retrospective cohort study at a tertiary referral center in Germany. All patients who were admitted within a 1-year period were included. Patient files were used to obtain the information.. Overall, 677 patients were included in our study. Of these, 159 had been treated with vitamin K antagonists and 49 with direct oral anticoagulants. There were no significant differences in terms of age (p = 0.592), sex (p = 0.372), vital signs, bloodwork, or location of bleeding (p = 0.372). Management of epistaxis between the groups was also comparable (p = 0.399), with similar hospital admission rates (37.1% vs 24.5%; p = 0.145) and duration of stay (3.5 ± 2.1 days vs 3.8 ± 3.3 days; p = 0.650).. We found no evidence to suggest epistaxis is more severe or requires more invasive therapy in patients given direct oral anticoagulants. A significant proportion of patients on vitamin K antagonists were not within the target range for international normalized ratio, highlighting one of the main issues with oral anticoagulation by vitamin K antagonists.

Topics: Administration, Oral; Aged; Aged, 80 and over; Anticoagulants; Cohort Studies; Dabigatran; Drug-Related Side Effects and Adverse Reactions; Epistaxis; Female; Follow-Up Studies; Germany; Hospitalization; Humans; Length of Stay; Male; Retrospective Studies; Risk; Rivaroxaban; Treatment Outcome; Warfarin

To describe the characteristics and severity of epistaxis in patients taking factor Xa inhibitors novel anticoagulants.. Retrospective cohort study.. 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.. 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.. Epistaxis under factor Xa inhibitors was effectively treated with no worse and perhaps even a better outcome when compared to other anticlotting medications.. 4 Laryngoscope, 129:119-123, 2019.

Topics: Aged; Anticoagulants; Epistaxis; Factor Xa Inhibitors; Female; Humans; Male; Middle Aged; Patient Readmission; Platelet Aggregation Inhibitors; Pyrazoles; Pyridones; Retrospective Studies; Rivaroxaban; Warfarin

Topics: Anticoagulants; Epistaxis; Factor Xa Inhibitors; Fibrinolytic Agents; Humans; Platelet Aggregation Inhibitors; Warfarin

Topics: Anticoagulants; Epistaxis; Factor Xa Inhibitors; Fibrinolytic Agents; Humans; Platelet Aggregation Inhibitors; Warfarin

Clinical variables including hypertension could be linked with major bleeding events and death beyond vitamin K antagonist (warfarin) or direct oral anti-coagulants (DOACs) treatment strategy.. Subgroup analysis of major bleeding (primary endpoint) associated with clinical variables, site of bleeding, ongoing antithrombotics, reversal treatment or blood transfusion, outcomes (secondary endpoints) was performed in patients with bleeding events submitted to hard 5:1 propensity-score matching for hypertension.. Enrolled patients were 2,792 (mean age, 65.6 ± 19.9 years) during 2-year survey including 166,000 visits, of 200,000 inhabitants catchment area; 8,239 patients received warfarin and 3,797 DOACs. Hypertension account for 1,077 (39%) patients; major bleeding for 474 (17%); death for 29 (1%), and 72 (3%) on 1-month and 1-year, respectively. Hypertension, age, glucose, cancer, ischemic vascular disease, and CHA2D2VASc score were more likely to link with major bleeding. On multivariate analysis, only age (odds ratio [OR], 1.02; P < 0.001), CHA2DS2VASc score ≥ 2 (OR, 2.14; P = 0.001), and glucose (OR, 1.01; P = 0.005) were predictors of major bleeding. Kaplan-Meier analysis demonstrated patients with hypertension as compared with patients without showed 60% versus 20% death on 1-month (P < 0.001). Warfarin compared with DOACs was more likely to present with major bleeding (0.7% versus 0.2%; OR, 2.8; P = 0.005). Receiver operator characteristics analysis showed high value (0.61) of age and glucose over creatinine and systolic arterial pressure (P = NS).. Four in 10 patients with major bleeding showed hypertension; of these 8 in 10 will die within 1 month. Warfarin compared with DOACs was more likely to present with major bleeding.

Topics: Adult; Age Factors; Aged; Aged, 80 and over; Anticoagulants; Blood Glucose; Blood Transfusion; Cardiovascular Diseases; Creatinine; Dabigatran; Emergency Service, Hospital; Epistaxis; Female; Gastrointestinal Hemorrhage; Hematuria; Hemoptysis; Hemorrhage; Humans; Hypertension; Intracranial Hemorrhages; Kaplan-Meier Estimate; Male; Middle Aged; Multivariate Analysis; Odds Ratio; Prognosis; Propensity Score; Pyrazoles; Pyridines; Pyridones; Rivaroxaban; Severity of Illness Index; Sex Factors; Thiazoles; Warfarin

This study aimed to compare management, readmission rates and length of in-patient stay amongst warfarinised and non-warfarinised patients to ascertain future treatment protocols.. A 12-month retrospective review was conducted of ENT epistaxis admissions. Admission details such as length of in-patient stay, clotting profile and management plan were recorded. Comparisons of management and outcome for warfarinised and non-warfarinised patients were made using the Fisher's exact paired t-test.. Of 176 epistaxis patients admitted, 31 per cent were warfarinised, 18 per cent were on another form of anticoagulation or antiplatelet therapy, and 51 per cent were not on any medication that might impose a bleeding risk. The international normalised ratio at admission was high in 13 per cent of warfarinised patients; the remaining patients had therapeutic or sub-therapeutic international normalised ratios and so warfarin was continued. The mean in-patient stay was similar for all cohorts; however, warfarinised patients had a higher readmission rate.. Warfarinised epistaxis patients may be safely managed without stopping their anticoagulation therapy, provided their international normalised ratio is at therapeutic or sub-therapeutic levels. By continuing regular anticoagulation therapy, warfarinised patients may be discharged without delay.

Topics: Adolescent; Adult; Aged; Aged, 80 and over; Anticoagulants; Cautery; Epistaxis; Female; Homeostasis; Humans; Length of Stay; Male; Middle Aged; Patient Readmission; Physical Therapy Modalities; Platelet Aggregation Inhibitors; Retrospective Studies; Warfarin; Young Adult

According to recent statistics more and more elderly patients are hospitalized due to epistaxis and need anticoagulation. Aim of the present study was to investigate if it was more complex to treat anticoagulated patients than non-anticoagulated patients, if these patients needed a longer hospital stay and to characterize the study population in terms of the various applied therapeutic methods.. Retrospective study, collecting clinical data of all in-patients treated between 1.1.2007 to 1.8.2011 at an ENT-Department of an University Clinic due to epistaxis.. Of 656 patients 265 were not anticoagulated, 391 were anticoagulated. The mean patients' age increased statistically significant. Patients without anticoagulation were significantly younger than patients with anticoagulation. The duration of the hospitalization differed significantly between the groups, with the longest for patients treated with warfarin (5.4 days). 71 patients underwent surgical treatment of epistaxis (cautery of the sphenopalatine artery or anterior ethmoid artery).. During the study period an increasing number of more elderly patients needed hospitalization due to epistaxis. The duration of hospitalization differed significantly between the groups, with longer stays for the anticoagulated patients. Currently, treatment of epistaxis patients however is reimbursed independently of the presence of comorbidities or anticoagulation therapy. For the further development of the German DRG System a new split of the epistaxis DRG should be considered.

Topics: Adolescent; Adult; Age Factors; Aged; Aged, 80 and over; Anticoagulants; Child; Child, Preschool; Costs and Cost Analysis; Diagnosis-Related Groups; Electrocoagulation; Epistaxis; Female; Germany; Health Care Costs; Humans; Infant; Length of Stay; Male; Middle Aged; Reimbursement Mechanisms; Retrospective Studies; Warfarin; Young Adult

Although a well-known complication in certain medical specialties, major bleeding due to the interaction between oral anticoagulants and antibiotics has been rarely reported concerning the upper aerodigestive tract. We report three cases of life-threatening bleeding of the upper aerodigestive tract in a context of antibiotic therapy in patients treated with oral anticoagulants.. Three male patients under coumadin anticoagulation therapy presented major bleeding in three different contexts (epistaxis, peritonsillar abscess and postoperative course after total laryngectomy). Surgical intervention for hemostasis was required in all cases, with coagulation correction in two. Complications were severe anemia (2/3) and chronic heart failure (1/3).. Interactions between two drugs commonly used in otolaryngology can result in major bleeding. The goal of this article is to raise practitioners' awareness of a potentially fatal, although rare, complication. We also review the main preventive strategies.

Topics: Administration, Oral; Aged; Anti-Bacterial Agents; Anticoagulants; Drug Interactions; Drug Therapy, Combination; Epistaxis; Follow-Up Studies; Hemorrhage; Humans; Male; Middle Aged; Nasopharyngeal Diseases; Postoperative Hemorrhage; Risk Factors; Treatment Outcome; Warfarin

To explore the influence of the single use of perinatal warfarin anticoagulation therapy on pregnancy outcome after the mechanical heart-valve replacement surgery in pregnant women.. Fifty-eight cases of pregnant women after heart-valve replacement surgery (2005.1-2009.12) received low-dose warfarin anticoagulation therapy. The perinatal outcomes included: (1) maternal complications: thrombosis, hemorrhage, heart failure, etc., and (2) adverse perinatal outcomes: miscarriage, stillbirth, neonatal death, fetal malformation, preterm delivery, such as warfarin syndrome.. In 58 patients, valve thrombosis was found in one case of pregnancy, general hemorrhage was found in 16 cases, spontaneous abortion was found in two cases, malformation was found in two cases. There were no stillbirth and neonatal death. Three cases were premature delivery. Thirty-two of 56 cases were late pregnancy vaginal delivery. Twenty-four cases were cesarean section produced, in which heart failure happened in 1 case and late postpartum hemorrhage happened in one case.. The low-dose and low-intensity warfarin anticoagulation therapy during pregnancy is good for patients with good compliance and low rate of fetal malformations and can effectively prevent maternal complications.

Topics: Abortion, Spontaneous; Adult; Anticoagulants; Aortic Valve; Cardiac Valve Annuloplasty; Cesarean Section; Congenital Abnormalities; Delivery, Obstetric; Ecchymosis; Epistaxis; Female; Gingival Hemorrhage; Heart Valve Prosthesis; Humans; Mitral Valve; Pregnancy; Premature Birth; Thrombosis; Warfarin; Young Adult

Topics: Adult; Aged; Aged, 80 and over; Anticoagulants; Atrial Fibrillation; Blood Coagulation Disorders; Contusions; Epistaxis; Female; Hematemesis; Humans; Male; Middle Aged; Vitamin K; Vitamins; Warfarin

Epistaxis can be caused or exacerbated by anticoagulant and antiplatelet therapy. This prospective study assessed the prevalence of epistaxis in patients taking anticoagulant and antiplatelet medication, and monitored differences in patients' clinical courses.. Prospective data were collected for consecutive patients referred with epistaxis from the emergency department over a seven-month period. Emergency department records were used to investigate prevalence and referral rates.. Over the study period, 290 patients presented to the emergency department with epistaxis; this represented 0.9 per cent of all emergency attendances. Of these patients, 119 (39 per cent) were referred on to the ENT department, 62 per cent of whom were currently taking anticoagulant or antiplatelet medication. Patients taking anticoagulant and antiplatelet medication were a significantly older group (relative risk 1.50 (1.08-2.28), p = 0.01) requiring longer in-patient stays (relative risk 2.50 (1.01-4.97), p = 0.01) and more aggressive local haemostasis measures. Most patients taking warfarin had an international normalised ratio outside the appropriate range for their disease. Hypertension was not a factor in these patients' clinical course.. Increasingly, emergency and ENT departments are being presented with epistaxis in patients taking anticoagulant or antiplatelet medication. A better understanding of such medication and its effects may enable more effective management of these patients.

Topics: Adult; Age Factors; Aged; Aged, 80 and over; Anticoagulants; Aspirin; Clopidogrel; Drug Therapy, Combination; Epistaxis; Hemostatic Techniques; Humans; International Normalized Ratio; Length of Stay; Middle Aged; Platelet Aggregation Inhibitors; Prevalence; Prospective Studies; Ticlopidine; Warfarin; Young Adult

Topics: Aged, 80 and over; Anti-Bacterial Agents; Anticoagulants; Bicuspid; Chronic Disease; Dental Caries; Epistaxis; Female; Follow-Up Studies; Humans; Incisor; International Normalized Ratio; Male; Middle Aged; Molar, Third; Oral Hemorrhage; Polypharmacy; Postoperative Complications; Tooth Extraction; Warfarin

We report a case of a 57-year-old patient with a history of a Starr-Edwards mitral valve prosthesis and DeBakey-Surgitool aortic valve prosthesis implanted 30 years ago who presented with symptoms consistent with class IV heart failure. The patient had been on no anticoagulation for approximately 30 years secondary to recurrent epistaxis occurring two years after starting warfarin therapy postoperatively. Throughout the patient's lifetime he experienced no thromboembolic complications from the lack of anticoagulation, despite developing concomitant atrial fibrillation approximately ten years prior to admission. In place of warfarin the patient had substituted large doses of aspirin. A workup revealed normal function of the mechanical valves for this extensive period.

Topics: Anticoagulants; Aortic Valve; Aspirin; Atrial Fibrillation; Endocarditis, Bacterial; Epistaxis; Heart Failure; Heart Valve Prosthesis; Heart Valve Prosthesis Implantation; Humans; Male; Middle Aged; Mitral Valve; Platelet Aggregation Inhibitors; Prosthesis Design; Self Medication; Thromboembolism; Time Factors; Treatment Outcome; Warfarin

Topics: Anticoagulants; Aortic Valve; Aspirin; Atrial Fibrillation; Endocarditis, Bacterial; Epistaxis; Heart Failure; Heart Valve Prosthesis; Heart Valve Prosthesis Implantation; Humans; Mitral Valve; Platelet Aggregation Inhibitors; Prosthesis Design; Self Medication; Thromboembolism; Time Factors; Treatment Outcome; Warfarin

Epistaxis is the most common nasal emergency and if nasal packing is required this commonly results in admission.. A literature search could find no published (UK) protocols for the management of this common condition in accident and emergency (A&E) departments. This paper presents a retrospective review of 116 patients with epistaxis, following implementation of the new peer reviewed protocol in June 2004.. Apart from cautery, 62 had nasal packing inserted. Only 17 required admission. Forty-six patients were discharged with nasal packing in situ and only seven (16 per cent) returned due to bleeding. The overall return rate was 11 per cent.. We feel this is a safe and logical protocol. Compared to mandatory admission after nasal pack insertion, we saved 39 admissions in five months. There were also the added benefits to patients of being able to recuperate at home rather than in hospital and avoidance of the risk of hospital acquired infection.

Topics: Adolescent; Adult; Aged; Aged, 80 and over; Anticoagulants; Clinical Protocols; Emergencies; Emergency Service, Hospital; England; Epistaxis; Female; Guideline Adherence; Hemostatic Techniques; Hospitalization; Humans; Male; Middle Aged; Patient Discharge; Peer Review, Health Care; Retrospective Studies; Tampons, Surgical; Warfarin

Topics: Anticoagulants; Arthritis, Juvenile; Child; Diagnosis, Differential; Epistaxis; Female; Hematuria; Humans; Infant; Kidney; Low Back Pain; Male; Prognosis; Urinalysis; Vitamin K Deficiency; Warfarin

Topics: Anticoagulants; Aspirin; Epistaxis; Hospitalization; Humans; Middle Aged; Warfarin

Topics: Anticoagulants; Drug Interactions; Epistaxis; Female; Humans; Middle Aged; Patient Compliance; Patient Education as Topic; Risk Factors; Vitamin K; Warfarin

A 61-year-old man with atrial fibrillation receiving Coumadin brand warfarin was switched to Barr brand warfarin without his knowledge as a result of a retail pharmacy dispensing error. The patient took the same dosage for 6-7 days and experienced severe epistaxis that required two visits to the emergency room. Previously, his coagulation values were within therapeutic range, but when tested at the emergency room the international normalized ratio was elevated. The patient denied changes in therapy compliance, diet, alcohol ingestion, or use of other drugs. His only other drug, taken periodically, was sildenafil for erectile dysfunction. Clinicians should be aware of differences between branded and generic compounds.

Topics: 3',5'-Cyclic-GMP Phosphodiesterases; Anticoagulants; Atrial Fibrillation; Drugs, Generic; Epistaxis; Humans; International Normalized Ratio; Male; Middle Aged; Phosphodiesterase Inhibitors; Piperazines; Purines; Sildenafil Citrate; Sulfones; Warfarin

Topics: Anticoagulants; Drugs, Generic; Epistaxis; Humans; International Normalized Ratio; Warfarin

Topics: Anticoagulants; Drugs, Generic; Epistaxis; Humans; International Normalized Ratio; Warfarin

Topics: Adult; Diagnosis, Differential; Ecchymosis; Emergency Medical Services; Epistaxis; Factitious Disorders; Female; Hematemesis; Humans; Rodenticides; Sex Offenses; Suicide, Attempted; Warfarin

Topics: Anticoagulants; Epistaxis; Humans; International Normalized Ratio; Male; Middle Aged; Prothrombin Time; Vitamin K; Warfarin

Topics: Adult; Aged; Anti-Inflammatory Agents, Non-Steroidal; Anticoagulants; Antihypertensive Agents; Aspirin; Electrocoagulation; Epistaxis; Female; Humans; Hypertension; Male; Middle Aged; Retrospective Studies; Tampons, Surgical; Warfarin

Topics: Adult; Drug Interactions; Epistaxis; Female; Fluconazole; Gingival Hemorrhage; Humans; Melena; Warfarin

Hypothetical clinical cases were used to investigate transfusion-related decision-making. Three red cell, three fresh frozen plasma (FFP) and three albumin transfusion decision cases were administered by questionnaire to 228 medical staff. The transfusion decision triggers were identified and comparisons made between resident and specialist groups and between Melbourne and Sydney participants. Factors important in red cell transfusion decisions included haemoglobin, symptoms of anaemia, presence of co-morbidities or surgery, gender, period of hospitalisation and the degree of documented blood loss. FFP administration was influenced by an abnormal coagulation test, the presence of co-morbidities and by the number of red cell units transfused. The administration of albumin, concentrated or 5% SPPS, was influenced by the period of hospitalisation and clinical circumstances such as a falling urine output postoperatively, and by the presence of hypotensive complications. Different transfusion responses were noted: resident staff transfused red cells and FFP earlier than specialists; Sydney specialists were more conservative of red cell transfusion; Melbourne specialists more conservative of FFP administration and surgeons were four times more likely to transfuse patients than physicians or anesthetists at certain haemoglobin values.

Topics: Abruptio Placentae; Adult; Aged; Ascites; Blood Component Transfusion; Blood Loss, Surgical; Blood Transfusion; Cesarean Section; Colonic Neoplasms; Decision Making; Disseminated Intravascular Coagulation; Epistaxis; Female; Humans; Hypoproteinemia; Male; Medical Staff, Hospital; Middle Aged; Peptic Ulcer Hemorrhage; Plasma; Pregnancy; Serum Albumin; Sex Factors; Warfarin; Wounds and Injuries

Two patients who developed hypoprothrombinemia and bleeding due to lovastatin-warfarin drug interaction are described. Because of the wider use of lovastatin and warfarin, heightened clinical awareness of this potentially serious interaction must be publicized. Therefore, prothrombin time should be monitored diligently when warfarin is prescribed to patients receiving lovastatin.

Topics: Atrial Fibrillation; Drug Interactions; Epistaxis; Gastrointestinal Hemorrhage; Hematuria; Humans; Hypercholesterolemia; Hypoprothrombinemias; Intracranial Embolism and Thrombosis; Lovastatin; Male; Middle Aged; Warfarin

To assess the aetiological contribution made to spontaneous epistaxis in adults over the age of 50 years by various groups of drugs, a controlled study was designed. Fifty-three consecutive epistaxis patients were compared with 50 controls. Significant differences were found between the groups in their consumption of warfarin, dipyridamole and non-steroidal anti-inflammatory drugs. Hypertension was equally common in the two groups, but tended to be less well controlled in the epistaxis patients compared to the controls. It is thought that the link between the use of nonsteroidal anti-inflammatory drugs and the occurrence of epistaxis may be due to alteration of platelet function.

Topics: Aged; Aged, 80 and over; Anti-Inflammatory Agents, Non-Steroidal; Arthritis; Coronary Disease; Dipyridamole; Epistaxis; Female; Humans; Hypertension; Lung Diseases, Obstructive; Male; Middle Aged; Prospective Studies; Warfarin

Topics: Aged; Epistaxis; Female; Hematuria; Humans; Influenza Vaccines; Nursing Homes; Theophylline; Warfarin

Potentiation of warfarin by trimethoprim-sulfamethoxazole (TMP-SMX) has been reported occasionally but not in the urologic literature. Three cases are presented in which significant bleeding developed when TMP-SMX was added for the patient already on warfarin anticoagulants. The mechanism of this interaction is uncertain but probably involves competitive protein binding by the two drugs.

Topics: Aged; Drug Synergism; Epistaxis; Female; Hematuria; Humans; Male; Middle Aged; Sulfamethoxazole; Trimethoprim; Warfarin

Topics: Adolescent; Adult; Contusions; Dipyridamole; Drug Interactions; Epistaxis; Female; Glomerulonephritis; Hematuria; Humans; Male; Middle Aged; Phenindione; Prothrombin Time; Warfarin