Warfarin-Associated Recurrent Epistaxis in a Patient with Supratherapeutic Anticoagulation: A Case Report

Abstract

Background:
Warfarin is a vitamin K antagonist used to prevent and treat thromboembolic disease. Its narrow therapeutic index means the international normalized ratio (INR) needs regular monitoring, because excessive anticoagulation can cause bleeding. Epistaxis is a common early sign of this problem.

Case Presentation:

A 60-year-old woman with coronary artery disease, a prior coronary artery bypass graft, and a past history of deep vein thrombosis presented with recurrent bilateral epistaxis. She was taking warfarin 5 mg daily with aspirin 75 mg daily. Bleeding came from both nostrils, more on the left, with a similar episode 15 days earlier that had resolved on its own. Examination showed mild pallor and bilateral inferior turbinate hypertrophy with blood staining. Laboratory testing showed a hemoglobin of 9.8 g/dL, a prothrombin time of about 48 seconds against a control of 12-14 seconds, and an INR of 4.8. Platelet count, renal function, and electrolytes were normal. Warfarin was stopped and the patient was given intravenous tranexamic acid, injectable vitamin K and local nasal measures. With these measures bleeding stopped without the need for nasal packing or cautery. The INR gradually fell to 2.5-3.0 within 48 hours. Warfarin was then restarted at a lower dose with close INR follow-up. Before discharge patient and her family were counselled on drug interactions, diet and warning signs of bleeding.

Conclusion:
Recurrent epistaxis in a patient on warfarin should prompt urgent INR testing and a review of all antithrombotic drugs. Prompt dose adjustment, local hemostatic measures and detailed counseling can control bleeding as well as preserve the benefit of anticoagulation.