Intractable Epistaxis with Febuxostat

Objective To report a case of serious, intractable epistaxis warranting an emergency department (ED) visit and hospital admission for transfusion following initiation of febuxostat. Case Summary An 86-year-old female presented to the ED after onset of intractable epistaxis for the previous 24 hours. Medications included aspirin, clopidogrel, metoprolol tartrate, valsartan, rosuvastatin, levothyroxine, esomeprazole, and febuxostat. She was treated with prednisone in the ED for a gout flare 3 weeks prior to the current visit, then was started on febuxostat at her follow-up primary care visit. Ten days after starting febuxostat therapy, she had onset of epistaxis. Initial treatment did not provide hemostasis and hemoglobin, and hematocrit values decreased. She was admitted and transfused. Aspirin, clopidogrel, and febuxostat were held during hospitalization. Bleeding subsided following bedside cautery. On hospital day 3, she restarted aspirin and clopidogrel and was discharged with no recurrence of bleeding. Discussion Epistaxis is relatively common and can be caused by multiple etiologies. Patient did not have prior episodes of epistaxis and had been on all medications for more than a year, except for febuxostat. This patient was also taking aspirin and clopidogrel; however, she had been taking these agents concomitantly for at least 4 years with no prior report of bleeding. Epistaxis occurred 10 days after the first dose of febuxostat with no other reported changes. Conclusions Epistaxis due to febuxostat use cannot be ruled out. Clinicians may consider alternate gout therapy in patients at high risk or taking medications that increase their risk for bleeding.