Class and Category
Pharmacologic Class: Calcium salts
Therapeutic Class: Antacid, anti-hypermagnesemic, anti-hyperphosphatemic, anti-hypocalcemic, calcium replacement, cardiotonic
Indications and Dosages
To treat hyperphosphatemia
CAPSULES, TABLETS (CALCIUM ACETATE)
Adults:
Initial: 2 capsules or tablets three times daily with meals. Dosage increased to reduce serum phosphorus level below 6 mg/dl as long as hypercalcemia doesn’t develop.
Usual: 3 or 4 capsules or tablets three times daily with each meal.
ORAL SOLUTION (CALCIUM ACETATE)
Adults:
Initial: Initial: 10 ml with each meal. Dosage increased every 2 to 3 wk to reduce serum phosphorus levels to the target range, as long as hypercalcemia doesn’t develop.
Usual: 15 to 20 ml with each meal.
To prevent hypocalcemia with oral supplementation
CAPSULES, ORAL SUSPENSION, TABLETS (CALCIUM CARBONATE); EFFERVESCENT TABLETS, TABLETS (CALCIUM CITRATE); TABLETS (CALCIUM GLUCONATE OR LACTATE)
Adults: 1,000 to 1,200 mg daily.
Pregnant and breastfeeding women: 1,000 to 1,300 mg daily.
Children ages 9 to 18: 1,300 mg daily.
Children ages 4 to 8: 1,000 mg daily.
Children ages 1 to 4: 700 mg daily.
Children ages 7 to 12 months: 260 mg daily.
Infants up to 6 months: 200 mg daily.
To provide antacid effects
CHEWABLE TABLETS, ORAL SUSPENSION, TABLETS (CALCIUM CARBONATE)
Adults and children age 12 and over: 350 to 1,500 mg 1 hr after meals and at bedtime, as needed.
To provide emergency treatment for hypocalcemia
I.V. INJECTION (CALCIUM CHLORIDE)
Adults: 500 to 1,000 mg given slowly over 5 to 10 min, repeated as needed.
I.V. INFUSION (CALCIUM GLUCONATE)
Adults with mild hypocalcemia: 1,000 to 2,000 mg infused over 2 hr.
Adults with severe hypocalcemia but without seizure or tetany: 0.5 mg/kg/hr, increased up to 2 mg/kg/hr, as needed. Maximum: 4,000 mg over 4 hr.
Infants and children with severe hypocalcemia but without tetany: 200 to 500 mg/kg/day as a continuous infusion or divided every 6 hr as intermittent infusions.
Neonates with severe hypocalcemia but without tetany: 200 to 800 mg/kg/day by continuous infusion or divided every 6 hr as intermittent infusions.
I.V. INJECTION, I.V. INFUSION (CALCIUM GLUCONATE)
Adults with tetany: 100 to 300 mg elemental calcium given as a bolus over 5 to 10 min, not to exceed 200 mg/min, followed by continuous infusion at 0.5 mg/kg/hr, increased to 2 mg/kg/hr, as needed, with rate adjusted, as needed, based on serum calcium levels.
Children with tetany: 100 to 200 mg/kg given as bolus over 10 min, not to exceed 100 mg/min, repeated after 6 hr, as needed. Alternatively, up to 500 mg/kg/day as continuous infusion with rate adjusted, as needed, based on serum calcium levels.
I.V. INJECTION, I.V. INFUSION (CALCIUM GLUCONATE)
Adults with tetany: 100 to 300 mg elemental calcium given as a bolus over 5 to 10 min, not to exceed 200 mg/min, followed by continuous infusion at 0.5 mg/kg/hr, increased to 2 mg/kg/hr, as needed, with rate adjusted, as needed, based on serum calcium levels.
Children with tetany: 100 to 200 mg/kg given as bolus over 10 min, not to exceed 100 mg/min, repeated after 6 hr, as needed. Alternatively, up to 500 mg/kg/day as continuous infusion with rate adjusted, as needed, based on serum calcium levels.
As an adjunct to treating magnesium intoxication
I.V. INJECTION (CALCIUM CHLORIDE)
Adults: 500 to 1,000 mg given over 2 to 5 min and repeated if CNS depression persists.
To treat arrhythmias associated with hyperkalemia, hypermagnesemia, or hypocalcemia
I.V. INJECTION (CALCIUM CHLORIDE)
Adults: 500 to 1,000 mg given slowly over 5 to 10 min.
To treat beta-blocker overdose that is refractory to glucagon and highdose vasopressor treatment
I.V. INJECTION (CALCIUM CHLORIDE)
Adults: 1,000 mg given via a central line.
To treat calcium channel blocker overdose
I.V. INFUSION (CALCIUM CHLORIDE)
Adults: 1,000 to 2,000 mg infused over 10 to 20 min, repeated every 20 min, as needed, up to 5 doses.
Mechanism of Action
Increases levels of intracellular and extracellular calcium, which is needed to maintain homeostasis, especially in the nervous and musculoskeletal systems. Also plays a role in normal cardiac and renal function, respiration, coagulation, and cell membrane and capillary permeability. Helps regulate the release and storage of neurotransmitters and hormones. Oral forms also neutralize or buffer stomach acid to relieve discomfort caused by hyperacidity.
Contraindications
Cardiac resuscitation with risk of existing digitalis toxicity or presence of ventricular fibrillation (I.V.), concurrent use of calcium supplements, hypercalcemia, hypersensitivity to calcium salts or their components, hypophosphatemia, renal calculi
Incompatibilities
To avoid precipitation, don’t give I.V. calcium chloride, or gluconate through the same I.V. line as bicarbonates, carbonates, phosphates, sulfates, or tartrates.
Interactions
DRUGS
Bisphosphonates (alendronate, etidronate, ibandronate, risedronate): Possibly decreased absorption of bisphosphonates
Calcium supplements, magnesium-containing preparations: Increased serum calcium or magnesium level, especially in patients with impaired renal function
Digitalis glycosides: Increased risk of arrhythmias
Fluoroquinolones: Reduced fluoroquinolone absorption by calcium carbonate
Iron salts: Decreased gastric iron absorption
Levothyroxine: Decreased absorption of levothyroxine
Tetracyclines: Decreased tetracycline absorption and blood level, leading to decreased anti-infective response
Thiazide diuretics: Possibly hypercalcemia
Verapamil: Reversed verapamil effects
Vitamin D (high doses): Excessively increased calcium absorption
FOODS
Caffeine, high-fiber food: Possibly decreased calcium absorption.
ACTIVITIES
Alcohol use (excessive), smoking: Possibly decreased calcium absorption
Adverse Reactions
CNS: Paresthesia (parenteral form)
CV: Hypotension, irregular heartbeat (parenteral form)
GI: Nausea or vomiting (parenteral form)
SKIN: Diaphoresis, flushing, or sensation of warmth (parenteral form)
Other: Hypercalcemia; injection-site burning, pain, rash, or redness (parenteral form)
Childbearing Considerations
PREGNANCY
- It is not known if drug can cause fetal harm.
- Be aware that pregnancy may alter dosage needs for mother
- Use with caution only if benefit to mother outweighs potential risk to fetus.
LACTATION
- Drug is present in breast milk.
- Patient should check with prescriber before breastfeeding. Dosage needs for mother may change if breastfeeding.
Nursing Considerations
- Store at room temperature, and protect from heat, moisture, and direct light. Don’t freeze.
- Warm solution to room temperature before parenteral administration.
- Keep patient in a recumbent position for 30 minutes after parenteral administration to prevent dizziness from hypotension.
- Administer I.V. calcium through an infusing I.V. solution using a small-bore needle inserted into a large vein to minimize irritation. Give calcium slowly to prevent excess calcium from reaching the heart and causing adverse cardiovascular reactions. Adverse reactions often result from too-rapid administration. If ECG tracings are abnormal or patient reports injection-site discomfort, expect to temporarily discontinue administration.
- Check regularly for infiltration because calcium causes necrosis. If infiltration occurs, stop infusion and tell prescriber immediately.
- Monitor serum calcium level, as ordered, and evaluate therapeutic response by assessing for Chvostek’s and Trousseau’s signs, which shouldn’t appear.
- Be aware that calcium chloride injection contains three times as much calcium per milliliter as calcium gluconate injection.
PATIENT TEACHING
- Urge patient to chew chewable tablets thoroughly before swallowing and to drink a glass of water afterward.
- Tell patient to shake bottle well before each use if suspension form is prescribed.
- Tell patient to dissolve calcium citrate effervescent tablets in water and drink immediately.
- Instruct patient to take calcium carbonate tablets 1 to 2 hours after meals and other forms with meals.
- Advise storing calcium at room temperature away from heat, moisture, and light. Warn against freezing suspension or syrup.
- Instruct patient to avoid taking calcium within 2 hours of another oral drug because of risk of interactions.
- Urge patient to ask prescriber before taking OTC drugs because of risk of interactions.
- Tell patient to avoid excessive use of tobacco and excessive consumption of alcoholic beverages, caffeine-containing products, and high-fiber foods because these substances may decrease calcium absorption.
- Remind patient to take calcium separate from other prescribed drugs. For example, tell the patient to take fluoroquinolone at least 2 hours before or 6 hours after calcium; if prescribed levothyroxine to take it at least 4 hours before or after calcium; if prescribed a tetracycline to take it at least 1 hour before calcium.
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