Amicar

aminocaproic acid

Amicar

Pharmacologic class: Carboxylic acid derivative

Therapeutic class: Antihemorrhagic, antifibrinolytic

Pregnancy risk category C

Action

Interferes with plasminogen activator substances and blocks action of fibrinolysin (plasmin)

Availability

Injection: 250 mg/ml

Syrup: 250 mg/ml

Tablets: 500 mg, 1,000 mg

Indications and dosages

➣ Excessive bleeding caused by fibrinolysis

Adults: 5 g P.O. during first hour; then 1 to 1.25 g/hour until drug blood level of 0.13 mg/ml is reached and sustained and bleeding is controlled. Or 4 to 5 g in 250 ml of compatible diluent I.V. over 1 hour, followed by continuous infusion of 1 g/hour in 50 ml of diluent. Continue for 8 hours or until bleeding stops. Maximum daily dosage is 30 g.

Off-label uses

• Dental extractions

• Hemorrhage

Contraindications

• Hypersensitivity to drug

• Disseminated intravascular coagulation

• Neonates (injectable form)

Precautions

Use cautiously in:

• heart, hepatic, or renal failure

• upper urinary tract bleeding.

Administration

• Dilute I.V. form in normal saline solution, dextrose 5% in water, or Ringer's solution for injection. Give at prescribed rate.

• Know that oral and I.V. doses are the

Adverse reactions

CNS: dizziness, malaise, headache, delirium, hallucinations, weakness, seizures

CV: hypotension, ischemia, thrombophlebitis, cardiomyopathy, bradycardia, arrhythmias

EENT: conjunctival suffusion, tinnitus, nasal congestion

GI: nausea, vomiting, diarrhea, abdominal pain, dyspepsia

GU: intrarenal obstruction, renal failure

Hematologic: bleeding tendency, generalized thrombosis, agranulocytosis, leukopenia, thrombocytopenia

Musculoskeletal: myopathy, rhabdomyolysis

Respiratory: dyspnea, pulmonary embolism

Skin: rash, pruritus

Interactions

Drug-drug. Estrogens, hormonal contraceptives: increased risk of hypercoagulation

Activated prothrombin, prothrombin complex concentrates: increased signs of active intravascular clotting

Drug-diagnostic tests. Alanine aminotransferase, aldolase, aspartate aminotransferase, blood urea nitrogen, creatinine, creatine kinase, potassium: increased levels

Drug-herbs. Alfalfa, anise, arnica, astragalus, bilberry, black currant seed oil, capsaicin, cat's claw, celery, chaparral, clove oil, dandelion, dong quai, evening primrose oil, feverfew, garlic, ginger, ginkgo, papaya extract, rhubarb, safflower oil, skullcap: increased anticoagulant effect

Coenzyme Q10, St. John's wort: reduced anticoagulant effect

Patient monitoring

• Monitor vital signs, fluid intake and output, and ECG.

See Assess for signs and symptoms of thrombophlebitis and pulmonary embolism.

See Monitor neurologic status, especially for signs of impending seizure.

• Monitor kidney and liver function test results, serum electrolyte levels, and CBC with white cell differential.

• Evaluate for blood dyscrasias, particularly bleeding tendencies.

Patient teaching

• Tell patient that drug may significantly affect many body systems. Assure him that he'll be monitored closely.

See Instruct patient to immediately report signs and symptoms of thrombophlebitis, pulmonary embolism, or unusual bleeding.

• Tell patient he'll undergo frequent blood testing during therapy.

• As appropriate, review all other significant and life-threatening adverse reactions and interactions, especially those related to the drugs, tests, and herbs mentioned above.

aminocaproic acid

(a-mee-noe-ka-pro-ik a-sid) aminocaproicacid,

Amicar

(trade name)

Classification

Therapeutic: hemostatic agents
Pharmacologic: fibrinolysis inhibitors
Pregnancy Category: C

Indications

Management of acute, life-threatening hemorrhage due to systemic hyperfibrinolysis or urinary fibrinolysis.Prevention of recurrent subarachnoid hemorrhage.Prevention of bleeding following oral surgery in hemophiliacs.Management of severe hemorrhage caused by thrombolytic agents.

Action

Inhibits activation of plasminogen.

Therapeutic effects

Inhibition of fibrinolysis.Stabilization of clot formation.

Pharmacokinetics

Absorption: Rapidly absorbed following oral administration.Distribution: Widely distributed.Metabolism and Excretion: Mostly eliminated unchanged by the kidneys.Half-life: Unknown.

Time/action profile (peak blood levels)

ROUTEONSETPEAKDURATION
POunknown2 hrN/A
IVunknown2 hrN/A

Contraindications/Precautions

Contraindicated in: Active intravascular clotting.Use Cautiously in: Upper urinary tract bleeding;Cardiac, renal, or liver disease (dosage reduction may be required);Disseminated intravascular coagulation (should be used concurrently with heparin); Obstetric / Lactation: Safety not established; Pediatric: Do not use products containing benzyl alcohol with neonates.

Adverse Reactions/Side Effects

Central nervous system

  • dizziness
  • malaise

Ear, Eye, Nose, Throat

  • nasal stuffiness
  • tinnitus

Cardiovascular

  • arrhythmias
  • hypotension (IV only)

Gastrointestinal

  • anorexia
  • bloating
  • cramping
  • diarrhea
  • nausea

Genitourinary

  • diuresis
  • renal failure

Musculoskeletal

  • myopathy

Interactions

Drug-Drug interaction

Concurrent use with estrogens, conjugated may result in a hypercoagulable state.Concurrent use with clotting factors may ↑ risk of thromboses.

Route/Dosage

Acute Bleeding Syndromes due to Elevated Fibrinolytic Activity

Oral (Adults) 5 g 1st hr, followed by 1–1.25 g q hr for 8 hr or until hemorrhage is controlled; or 6 g over 24 hr after prostate surgery (not >30 g/day).Intravenous (Adults) 4–5 g over 1st hr, followed by 1 g/hr for 8 hr or until hemorrhage is controlled; or 6 g over 24 hr after prostate surgery (not >30 g/day).Oral Intravenous (Children) 100 mg/kg or 3 g/m2 over 1st hr, followed by continuous infusion of 33.3 mg/kg/hr; or 1 g/m2/hr (total dose not >18 g/m2/24 hr).

Subarachnoid Hemorrhage

Oral (Adults) To follow IV—3 g q 2 hr (36 g/day). If no surgery is performed, continue for 21 days after bleeding stops, then decrease to 2 g q 2 hr (24 g/day) for 3 days, then 1 g q 2 hr (12 g/day) for 3 days.Intravenous (Adults) 36 g/day for 10 days followed by PO.

Prevention of Bleeding Following Oral Surgery in Hemophiliacs

Oral (Adults) 75 mg/kg (up to 6 g) immediately after procedure, then q 6 hr for 7–10 days; syrup may also be used as an oral rinse of 1.25 g (5 mL) 4 times a day for 7–10 days.Intravenous Oral (Children) Also for epistaxis—50–100 mg/kg/dose administered IV every 6 hr for 2–3 days starting 4 hr before the procedure. After completion of IV therapy, aminocaproic acid should be given as 50–100 mg/kg/dose orally every 6 hr for 5–7 days.

Availability

Tablets: 500 mg, 1000 mg Syrupraspberry flavor: 1.25 g/5 mL Injection: 250 mg/mL

Nursing implications

Nursing assessment

  • Monitor BP, pulse, and respiratory status as indicated by severity of bleeding.
  • Monitor for overt bleeding every 15–30 min.
  • Monitor neurologic status (pupils, level of consciousness, motor activity) in patients with subarachnoid hemorrhage.
  • Monitor intake and output ratios frequently; notify physician if significant discrepancies occur.
  • Assess for thromboembolic complications (especially in patients with history). Notify health care professional of positive Homans’ sign, leg pain and edema, hemoptysis, dyspnea, or chest pain.
  • Lab Test Considerations: Monitor platelet count and clotting factors prior to and periodically throughout therapy in patients with systemic fibrinolysis.
    • ↑ CPK, AST, and serum aldolase may indicate myopathy.
    • May ↑ serum potassium.

Potential Nursing Diagnoses

Ineffective tissue perfusion (Indications)
Risk for injury (Indications, Side Effects)

Implementation

  • Oral: Syrup may be used as an oral rinse, swished for 30 sec 4 times/day for 7–10 days for the control of bleeding during dental and oral surgery in hemophilic patients. Small amounts may be swallowed, except during 1st and 2nd trimesters of pregnancy. Syrup may be applied with an applicator in children or unconscious patients.
  • Intravenous Administration
  • pH: 6–7.6.
  • Intravenous: Stabilize IV catheter to minimize thrombophlebitis. Monitor site closely.
  • Intermittent Infusion: Diluent: Do not administer undiluted. Dilute initial 4–5 g dose in 250 mL of sterile water for injection, 0.9% NaCl, D5W, or LR. Do not dilute with sterile water in patients with subarachnoid hemorrhage.Concentration: 20 mg/mL.
  • Rate: Single doses: Administer over 1 hr. Rapid infusion rate may cause hypotension, bradycardia, or other arrhythmias.
  • Continuous Infusion: Administer IV solution using infusion pump to ensure accurate dose. Administer via slow IV infusion.
  • Rate: Initial dose may be followed by a continuous infusion of 1–1.25 g/hr in adults or 33.3 mg/kg/hr in children.
  • Y-Site Compatibility: alemtuzumab, alfentanil, amikacin, aminophylline, amphotericin B colloidal, amphotericin B lipid complex, amphotericin B liposome, ampicillin, ampicillin/sulbactam, anidulafungin, argatroban, atracurium, azithromycin, aztreonam, bivalirudin, bleomycin, bumetanide, buprenorphine, butorphanol, calcium chloride, calcium gluconate, carboplatin, carmustine, cefazolin, cefepime, cefoperazone, cefotaxime, cefotetan, ceftazidime, ceftriaxone, cefuroxime, cisatracurium, clindamycin, cyclophosphamide, cyclosporine, cytarabine, daptomycin, dexamethasone, dexmedetomidine, digoxin, diltiazem, diphenhydramine, dobutamine, docetaxel, dopamine, doxacurium, droperidol, enalaprilat, ephedrine, epinephrine, epirubicin, ertapenem, erythromycin, esmolol, etoposide, etoposide phosphate, famotidine, fenoldopam, fentanyl, fluconazole, fludarabine, foscarnet, fosphenytoin, furosemide, gemcitabine, gentamicin, granisetron, haloperidol, heparin, hydrocortisone, hydromorphone, idarubicin, ifosfamide, imipenem/cilastatin, irinotecan, isoproterenol, ketorolac, labetalol, levofloxacin, levorphanol, lidocaine, linezolid, lorazepam, magnesium sulfate, mannitol, mechlorethamine, meperidine, meropenem, methohexital, methylprednisolone, metoclopramide, metoprolol, metronidazole, milrinone, mitoxantrone, morphine, nalbuphine, naloxone, nesiritide, nitroglycerin, nitroprusside, octreotide, ondansetron, oxaliplatin, oxytocin, palonosetron, pamidronate, pantoprazole, pamidronate, pancuronium, pantoprazole, pemetrexed, pentamidine, pentobarbital, phenobarbital, phenylephrine, piperacillin/tazobactam, potassium acetate, potassium chloride, potassium phosphates, procainamide, promethazine, propranolol, ranitidine, remifentanil, rocuronium, sargramostim, sodium bicarbonate, sodium phosphates, succinylcholine, sufentanil, tacrolimus, teniposide, theophylline, thiotepa, ticarcillin/clavulanate, tigecycline, tirofiban, tobramycin, trimethoprim/sulfamethoxazole, vancomycin, vasopressin, vecuronium, verapamil, vincristine, voriconazole, zidovudine, zoledronic acid
  • Y-Site Incompatibility: acyclovir, amiodarone, caspofungin, chlorpromazine, ciprofloxacin, diazepam, dolasetron, doxycycline, filgrastim, ganciclovir, midazolam, mycophenolate, nicardipine, phenytoin, prochlorperazine, quinupristin/dalfopristin, thiopental
  • Additive Incompatibility: Do not admix with other medications.

Patient/Family Teaching

  • Instruct patient to notify the nurse immediately if bleeding recurs or if thromboembolic symptoms develop.
  • Intravenous: Caution patient to make position changes slowly to avoid orthostatic hypotension.

Evaluation/Desired Outcomes

  • Cessation of bleeding.
  • Prevention of rebleeding in subarachnoid hemorrhage without occurrence of undesired clotting.