calcium

Calcium Supplements
Mineral Binding Agents

In general, administer with meals for improved absorption. Follow each dose with adequate fluids.
Because calcium-containing products may interfere with the absorption of other medicines, separate administration of calcium from other medications according to recommendations for the potentially interacting medication.

The parenteral formulation of calcium gluconate has been diluted in feedings for oral administration in neonates and infants.

Administer intravenously. Do NOT administer intramuscularly or subcutaneously.
Visually inspect parenteral products for particulate matter and discoloration prior to administration whenever solution and container permit.
Calcium gluconate 10% (100 mg/mL) contains approximately 9 mg/mL of elemental calcium.

Intermittent IV Infusion
May dilute in compatible IV solution (i.e., 0.9% Sodium Chloride injection, 5% Dextrose injection, 10% Dextrose injection) to a usual concentration of 10 to 40 mg/mL.
Neonates:
A recommended concentration for peripheral lines is 3 mg/mL for neonates; however, concentrations as high as 100 mg/mL have been used for bolus doses. Observe the infusion line closely. Higher concentrations have been given via central lines.
Do not administer via scalp vein catheter.
Generally, infuse a bolus dose over 30 to 60 minutes. Calcium gluconate may be administered at a rate not exceeding 200 mg/minute.
 
IV Push
In general, inject IV 10% calcium gluconate products slowly, at a rate of 1.5 mL/minute (150 mg/minute) or less to avoid adverse reactions. The product labeling recommends an absolute maximum rate of 2 mL/minute (200 mg/minute); however, for life-threatening cardiac arrhythmias during cardiopulmonary resuscitation, bolus doses are given over 2 to 5 minutes. Administer through a small needle into a large vein.

Intraosseous Route
Calcium gluconate is not approved by the FDA for intraosseous administration.
During cardiopulmonary resuscitation in pediatrics, calcium gluconate may be given via the intraosseous route when IV access is not available.

tissue necrosis / Early / Incidence not known
AV block / Early / Incidence not known
coma / Early / Incidence not known
ventricular fibrillation / Early / Incidence not known
bradycardia / Rapid / Incidence not known
cardiac arrest / Early / Incidence not known
aluminum toxicity / Delayed / Incidence not known

hypotension / Rapid / Incidence not known
constipation / Delayed / Incidence not known
delirium / Early / Incidence not known
hypercalcemia / Delayed / Incidence not known
peripheral vasodilation / Rapid / Incidence not known
confusion / Early / Incidence not known
hypertension / Early / Incidence not known
premature ventricular contractions (PVCs) / Early / Incidence not known
nephrolithiasis / Delayed / Incidence not known

injection site reaction / Rapid / Incidence not known
vomiting / Early / Incidence not known
polyuria / Early / Incidence not known
syncope / Early / Incidence not known
flushing / Rapid / Incidence not known
anorexia / Delayed / Incidence not known
nausea / Early / Incidence not known
drowsiness / Early / Incidence not known
dizziness / Early / Incidence not known
paresthesias / Delayed / Incidence not known
dysgeusia / Early / Incidence not known

Calcitrate, Calphron, Eliphos, Oysco 500, PhosLo, Phoslyra

Rx, OTC

Calcium salt of gluconic acid; contains approximately 9% elemental calcium, which is about one-third of the calcium content in calcium chloride
Used intravenously for hypocalcemia or life-threatening cardiac arrhythmias associated with documented hypocalcemia, hyperkalemia, or hypermagnesemia
Preferred in the nonarrest setting for mild to moderate, asymptomatic hypocalcemia due to the lower potential for infusion site reactions compared with calcium chloride

1 to 2 g IV given over 10 to 60 minutes. May repeat every 6 hours as needed, as determined by serum calcium concentrations and patient response. Doses as high as 4 g IV infused over 4 hours have been used. Alternatively, a continuous infusion of 5 to 21 mg/kg/hour calcium gluconate (0.5 to 2 mg/kg/hour elemental calcium) IV may be administered if symptoms recur after initial IV calcium replacement. Titrate dose based on serum calcium concentrations.

Initial bolus of 100 to 200 mg/kg/dose IV given over 10 to 60 minutes (Max: 2 g/dose). May repeat bolus every 6 hours as needed, as determined by serum calcium concentrations and patient response. Alternatively, a continuous infusion of 5 to 21 mg/kg/hour calcium gluconate (0.5 to 2 mg/kg/hour elemental calcium) IV may be administered if symptoms recur after initial IV calcium replacement. Titrate dose according to serum calcium concentrations.

Initial bolus of 100 to 200 mg/kg/dose IV given over 10 to 60 minutes. May repeat bolus every 6 hours as needed, as determined by serum calcium concentrations and patient response. Alternatively, a continuous infusion of 5 to 32 mg/kg/hour calcium gluconate (0.5 to 3 mg/kg/hour elemental calcium) IV may be administered if symptoms recur after initial IV calcium replacement. Titrate dose according to serum calcium concentrations. In neonates, continuous infusion of calcium is preferred to IV bolus doses.

NOTE: The IV preparation of calcium gluconate may be given orally.

40 to 80 mg elemental calcium/kg/day PO in 3 to 4 divided doses (Usual Max: 2,000 mg/day; 500 mg/dose).

40 to 100 mg elemental calcium/kg/day PO in 4 to 6 divided doses, given with feedings.

10 to 15 mEq/day IV. Total calcium amounts may be limited due to calcium/phosphate incompatibility. Individualize dosing according to monitoring.

10 to 20 mEq/day IV. Total calcium amounts may be limited due to calcium/phosphate incompatibility. Individualize dosing according to monitoring.

0.5 to 4 mEq/kg/day IV. Total calcium amounts may be limited due to calcium/phosphate incompatibility. Individualize dosing according to monitoring.

2 to 4 mEq/kg/day IV. Higher calcium requirements are necessary in premature and term neonates compared with older children; however, total calcium amounts may be limited due to calcium/phosphate incompatibility. Individualize dosing according to monitoring.

1,200 mg/day elemental calcium PO is the recommended dietary allowance (RDA). To prevent the development of osteoporosis in postmenopausal women, most reference texts recommend an intake of 1 to 1.5 g/day PO of elemental calcium; the 2006 guidelines of the North American Menopause Society recommend a target intake of 1,200 mg/day of elemental calcium PO in postmenopausal women. A dose of 1,000 mg/day PO of elemental calcium was superior to placebo in a randomized study of 122 women; however, this same dose of elemental calcium was less effective than calcitriol in preventing new vertebral fractures in a separate study of postmenopausal women.

1,000 mg/day elemental calcium PO is the recommended dietary allowance (RDA). To prevent the development of osteoporosis in postmenopausal women, most reference texts recommend an intake of 1 to 1.5 g/day PO of elemental calcium; the 2006 guidelines of the North American Menopause Society recommend a target intake of 1,200 mg/day of elemental calcium PO in postmenopausal women. A dose of 1,000 mg/day PO of elemental calcium was superior to placebo in a randomized study of 122 women; however, this same dose of elemental calcium was less effective than calcitriol in preventing new vertebral fractures in a separate study of postmenopausal women.

1,200 mg/day elemental calcium PO is the recommended dietary allowance (RDA).

1,000 mg/day elemental calcium PO is the recommended dietary allowance (RDA).

1,300 mg/day elemental calcium PO is the recommended dietary allowance (RDA).

1,500 to 3,000 mg (15 to 30 mL of a 10% solution) IV over 2 to 5 minutes; may repeat if needed.

60 to 100 mg/kg/dose (Max: 3 g/dose) IV or Intraosseous (0.6 to 1 mL/kg); may repeat if needed. Calcium chloride is the preferred salt because it is in the ionized form and leads to a greater increase in ionized calcium; however, calcium gluconate may be used if calcium chloride is unavailable.

60 to 100 mg/kg/dose IV or Intraosseous (0.6 to 1 mL/kg); may repeat if needed. Calcium chloride is the preferred salt because it is in the ionized form and leads to a greater increase in ionized calcium; however, calcium gluconate may be used if calcium chloride is unavailable.

300 mg (approximately 1.4 mEq elemental calcium) IV for each 100 mL of citrated blood infused has been recommended.

300 mg (approximately 1.4 mEq elemental calcium) IV for each 100 mL of citrated blood infused has been recommended.

98 mg (0.465 mEq elemental calcium) IV for each 100 mL of citrated blood exchanged has been used. However, studies have reported that although decreases in ionized calcium concentrations occurred during exchange transfusion, the decreases were transient and normalized spontaneously and hypocalcemia as a complication did not occur in groups who did not receive calcium supplementation. One study in 18 neonates found no difference in ionized calcium concentrations between patients who received calcium gluconate and those who did not. Studies have suggested that routine supplementation is not necessary in most patients and supplementation should be considered in high-risk patients (i.e., very low birth weight infants with complicated history and repeated exchange transfusions).

†Indicates off-label use

Specific guidelines for dosage adjustments in hepatic impairment are not available; it appears that no dosage adjustments are needed. Adjust dosage based on patient response and serum calcium concentrations.

Specific guidelines for dosage adjustments in renal impairment are not available; it appears that no dosage adjustments are needed. Adjust dosage based on patient response and serum calcium concentrations.

Monograph content under development

Calcitrate/Calcium/Calcium Acetate/Calcium Citrate/Calcium Gluconate/Calphron/Eliphos/Oysco 500/PhosLo Oral Tab: 84mg, 200mg, 500mg, 667mg, 668mg, 950mg
Calcium/Calcium Acetate/PhosLo Oral Cap: 667mg
Calcium/Calcium Chloride/Calcium Gluconate Intravenous Inj Sol: 1mL, 10%, 100mg
Calcium/Calcium Glubionate/Phoslyra Oral Sol: 1.8g, 5mL, 667mg

Generally, 3 g IV as a single bolus dose.

Generally, 3 g IV as a single bolus dose.

Generally, 200 mg/kg/dose (Max: 3 g/dose) IV as a single bolus dose; 80 mg elemental calcium/kg/day PO for hypocalcemia.

Generally, 200 mg/kg/dose (Max: 3 g/dose) IV as a single bolus dose; 80 mg elemental calcium/kg/day PO for hypocalcemia.

Generally, 200 mg/kg/dose IV as a single bolus dose; 80 mg elemental calcium/kg/day PO for hypocalcemia.

Generally, 200 mg/kg/dose IV as a single bolus dose; 100 mg elemental calcium/kg/day PO for hypocalcemia.

Calcium is the primary component of skeletal tissue, providing structural integrity and support for individual growth. Bone undergoes constant remodeling and turnover. Mineral release during the process of bone resorption buffers hydrogen ions, whereas the formation of bone generates hydrogen ions. Thus, bone serves as a calcium depot and as a reservoir for electrolytes and buffers. Inhibition of bone resorption is primarily the function of the hormone, calcitonin. The control of plasma calcium concentration is primarily maintained by parathyroid hormone, thyroxine, and 1,25 dihydroxycholecalciferol. Ionized calcium is the physiologically active form. Basic metabolic functions involve the cardiac, neuromuscular, structural, and blood coagulation systems.

Calcium gluconate is administered orally, intravenously, or intraosseously†. Calcium is required by all body tissues. Approximately 98% of the body's calcium is stored in the bone, primarily as the hydroxyapatite. Constant bone remodeling and turnover of the skeleton release calcium into the systemic circulation which is then re-accumulated by the bone on a daily basis. Calcium is 40% bound to plasma proteins, primarily albumin, and 10% is in a chelated form. Approximately 50% of serum calcium is ionized, which is considered the physiologically active form. The ultrafiltratable calcium (nonprotein-bound) is distributed to the protein-poor regions of the body, such as the cerebrospinal and extracellular fluids. Calcium is primarily excreted in the feces and bile (80%). Urinary excretion accounts for the remainder (20%). However, approximately 99% of filtered calcium is reabsorbed by the kidney with less than 1% excreted. Parathyroid hormone, calcitonin, and 1,25 dihydroxycholecalciferol are primarily responsible for controlling calcium equilibrium. Insulin, thyroxine, growth hormone, androgens, estrogens, adrenal corticosteroids, and inorganic phosphate also contribute.
 
Affected cytochrome P450 isoenzymes: none

Animal reproduction studies have not been conducted with calcium gluconate. It is unknown if calcium gluconate can cause fetal harm when administered during pregnancy or can affect reproductive capacity. Calcium gluconate should be given to a pregnant woman only if clearly needed.

There are no data available on the presence of calcium gluconate in human milk, the effect on the breastfed infant, or the effect on milk production. Consider the benefits of breast-feeding, the risk of infant drug exposure, and the risk of an untreated or inadequately treated condition.