Nosebleeds, also known as epistaxis, are a common problem that most people will experience at some point in their lives. They occur when one of the blood vessels in the nose ruptures and bleeds. In most cases, nosebleeds are minor and can be easily stopped with simple first aid measures like applying pressure to the nose. However, they can sometimes be prolonged or severe, especially if a person is taking certain medications that interfere with normal blood clotting and healing of the nasal tissues. Many drugs that are commonly used on a daily basis have side effects that make users more susceptible to nosebleeds or make them harder to stop once they start. Being aware of how your medications affect nasal and vascular health can help prevent problematic nosebleeds.
Blood thinners are a category of anticoagulant medications that work by inhibiting clot formation. This prevents dangerous blood clots from blocking arteries and causing heart attacks, strokes, and other serious cardiovascular problems. However, it also impairs the body’s normal clotting ability throughout the body. When the fragile capillaries inside the nose bleed, the blood thinner makes it harder for a clot to form and seal off the leak. This allows the bleeding to continue unabated and result in a significant nosebleed.
Warfarin (brand names Coumadin and Jantoven) is one of the most widely prescribed blood thinners. It is commonly used in people with atrial fibrillation, deep vein thrombosis, pulmonary embolism, or mechanical heart valves. Studies show that when taken long-term, warfarin can increase the annual risk of nosebleeds by up to 10 times compared to people not taking anticoagulants. This is because it inhibits vitamin K-dependent clotting factors in the blood. Patients on warfarin need to limit activities that could cause nose trauma and be vigilant about applying prolonged pressure if they do get a nosebleed.
Direct Oral Anticoagulants
Newer direct oral anticoagulants (DOACs) including dabigatran, rivaroxaban, apixaban, and edoxaban are increasingly used instead of warfarin for many indications. They have more predictable dosing and effects without the need for monitoring. However, DOACs also increase overall bleeding risk including nosebleeds. In clinical trials, nosebleeds occurred in 2.9-10.3% of patients taking DOACs compared to just 1.8-6.8% of those on warfarin. So the medications have similar impacts on nasal bleeding.
Heparin is administered intravenously and used in hospitals to prevent blood clots. When patients first start taking it, the effects are immediate and unpredictable. This often leads to nosebleeds soon after starting heparin therapy. Patients need close monitoring when first placed on heparin until stable and therapeutic levels are achieved. After leaving the hospital, heparin nosebleeds are no longer a concern.
Antiplatelet drugs like aspirin, clopidogrel (Plavix), ticagrelor (Brilinta) and others are often taken to prevent blood clots leading to heart attacks and strokes. They work by preventing platelets from sticking together and forming clots. This also inhibits clot formation if small nasal capillaries are damaged. Low dose aspirin approximately doubles the risk of recurrent nosebleeds according to research studies. This risk is dose-dependent, with higher doses causing more bleeding problems. Combining multiple antiplatelet medications further exacerbates this issue.
Nasal decongestants like oxymetazoline (Afrin) and phenylephrine (Neo-Synephrine) are used to temporarily relieve nasal congestion associated with colds, allergies, and sinusitis. They work by constricting blood vessels inside the nose to open up the nasal airways. However, rebound swelling occurs when the medications wear off, leaving blood vessels dilated. This sets the stage for nosebleeds. Chronic use beyond 3 days can create a cycle of worsening congestion and recurrent bleeding as the nasal tissue becomes dependent on the drugs.
Corticosteroid pills and syrups such as prednisone, dexamethasone and methylprednisolone are prescribed for many inflammatory conditions like asthma, rheumatoid arthritis, and inflammatory bowel diseases. They raise risk of nosebleeds in a few different ways. First, steroids of all types can increase blood pressure, which puts more pressure on delicate nasal capillaries. They also impair wound healing throughout the body which can hinder scab formation after a bleed starts. And orally, steroids may cause thinning of the nasal lining which makes blood vessels more prone to rupture.
Intranasal corticosteroid sprays like fluticasone (Flonase) and mometasone (Nasonex) are very commonly used for allergic rhinitis. They decrease inflammation which can improve symptoms of congestion. However, they also cause thinning and drying of the nasal lining with long term use. This increases fragility of nasal blood vessels and likelihood of nosebleeds, especially during winter months when nasal irritation is more common. Those already prone to nosebleeds may find them worsening with daily use of nasal steroid sprays.
Non-steroidal anti-inflammatory drugs (NSAIDs) like ibuprofen (Advil, Motrin), naproxen (Aleve), diclofenac and others are frequently used to manage pain and inflammation for conditions like arthritis. By inhibiting prostaglandins involved in the body’s pain and inflammation pathways, NSAIDs also end up interfering with platelet activation and blood clotting mechanisms. Heavy or frequent NSAID use has been associated with a higher prevalence of nosebleeds. People who already experience recurrent nosebleeds many find them more difficult to control when taking NSAIDs regularly.
Many common antidepressant medications can contribute to bloody noses as well. This includes older drugs like fluoxetine (Prozac), paroxetine (Paxil), sertraline (Zoloft) and citalopram (Celexa) as well as newer options like venlafaxine (Effexor), duloxetine (Cymbalta) and desvenlafaxine (Pristiq). These selective serotonin reuptake inhibitor (SSRI) and serotonin-norepinephrine reuptake inhibitor (SNRI) drugs make platelets less able to clump and form clots. They have also been linked to reduced clotting factors in blood tests. All of these effects impair the closure of broken blood vessels. Bleeding time and risk of bruising is increased.
Supplements and Vitamins
Several nutritional supplements can act as natural blood thinners and impact clotting. These include:
– Fish oil – rich in omega-3s that inhibit platelet aggregation
– Vitamin E – anti-platelet effects in high doses
– Ginkgo biloba – blocks platelet activating factor
– Garlic – anti-platelet activity
– Turmeric/curcumin – anticoagulant properties
– Dong quai – contains coumarins with blood thinning effects
– Ginger – inhibits thromboxane synthesis
People prone to nosebleeds should use these supplements cautiously and stop them if bleeds become more frequent or severe. Ensuring adequate Vitamin K intake from green leafy vegetables can counteract some of these anticoagulant effects. Multivitamins often contain vitamin E and should be used sparingly by those with clotting disorders.
Various other pharmaceutical drugs have also been linked to nosebleeds, although the evidence is weaker and their use less common. These drugs include:
– Isotretinoin (Accutane) for acne – dries mucous membranes
– Sildenafil (Viagra) for erectile dysfunction – impairs platelet function
– Anti-hypertensives like ACE inhibitors and calcium channel blockers – may inhibit platelet aggregation
– Chemotherapy agents – myeloablative properties impair platelet production
– Bisphosphonates like alendronate (Fosamax) – may cause inflammation and erosion of nasal lining
Preventing Drug-Induced Nosebleeds
For patients taking medications linked to nosebleeds, there are some basic precautions that can minimize risk:
– Use saline nasal sprays to keep nasal passages moisturized
– Avoid overusing nasal decongestant sprays
– Treat allergies, sinus problems, and nasal irritants promptly
– Quit smoking which dries and damages nasal tissue
– Have nosebleeds evaluated by an otolaryngologist if severe or recurrent
– Inform all doctors of bleeding concerns prior to procedures
– Monitor INR closely if taking warfarin and adjust dose accordingly
– Take shorter NSAID courses and use topical rather than oral when possible
– Try an electronic home humidifier, especially in winter
– Lubricate with nasal gels before bed if prone to nighttime nosebleeds
Sometimes switching medications or lowering dosages may be warranted if nosebleeds become problematic. But never stop prescribed drugs without consulting your physician first. Preventative strategies, prompt treatment of bleeds, and monitoring for changes in severity are key to managing nosebleeds related to anticoagulant, antiplatelet, drying, and other blood-thinning medications.
Treating Acute Bleeds
If a nosebleed occurs, take proper first aid measures to control bleeding:
– Stay calm and do not tilt head back
– Apply firm continuous pressure by pinching nasal soft tissues together between thumb and index finger for at least 5-10 minutes – this is usually most effective for minor bleeds. Do not let go or keep checking if bleeding has stopped.
– Apply cold compress across bridge of nose
– Use nasal decongestant spray to constrict blood vessels once bleeding fully stops
– Avoid nose blowing, strenuous activity, hot drinks, and alcohol immediately after to prevent rebleeding
See a doctor promptly if you are unable to stop bleeding after 30 minutes of direct pressure or if nosebleeds are very heavy, last longer than usual, or occur more often. Severe uncontrollable epistaxis may require professional interventions like cauterization, prescription hemostatic agents, or packing to stem the flow of blood. Call 911 or go to emergency care if nosebleed bleeding is extremely heavy or you suddenly feel faint and lightheaded.
Many medications taken routinely can increase risk of nosebleeds occurring and make them harder to staunch if they do happen. Common culprits include blood thinners, nasal decongestants, steroids, NSAIDs, antidepressants, herbal supplements with anticoagulant properties, and some vitamins. Those prone to nosebleeds should be aware if they are taking any drugs associated with impaired clotting or adverse effects on nasal blood vessels or mucosa. Preventative nasal hygiene practices, prompt bleeding control measures, and working with your doctor to minimize causative medications can reduce frequency and severity of medication-induced epistaxis. While annoying and sometimes frightening, drug-related nosebleeds can often be effectively managed with self-care techniques and medical assistance as needed.