| Mode Of Action | In its use as poisoning antidote, calcium antagonizes blockade of calcium channels by drugs besides altering membrane polarization and chelating fluoride ions. |
|---|---|
| Drug Indication | Magnesium toxicity; severe hyperkalaemia not related to digoxin toxicity; acute calcium channel blocker poisoning with heart block and burns from hydrofluoric acid. |
| Side Effects | Hypersensitivity |
Calcium gluconate may be confused with calcium glubionate
Adequate Intake (as elemental calcium):
Adults, Male/Female:
19-50 years: 1000 mg/day
≥51 years: 1200 mg/day
Female: Pregnancy/Lactating: Same as for Adults, Male/Female
Dosage note: Calcium chloride has 3 times more elemental calcium than calcium gluconate. Calcium chloride is 27% elemental calcium; calcium gluconate is 9% elemental calcium. One gram of calcium chloride is equal to 270 mg of elemental calcium; 1 gram of calcium gluconate is equal to 90 mg of elemental calcium. The following dosages are expressed in terms of the calcium gluconate salt based on a solution concentration of 100 mg/mL (10%) containing 0.465 mEq (9.3 mg)/mL elemental calcium:
Hypocalcemia:
I.V.: 2-15 g/24 hours as a continuous infusion or in divided doses
Oral: 500 mg to 2 g 2-4 times/day
Hypocalcemia secondary to citrated blood infusion: I.V.: 500 mg to 1 g per 500 mL of citrated blood (infused into another vein). Single doses up to 2 g have also been recommended.
Note: Routine administration of calcium, in the absence of signs/symptoms of hypocalcemia, is generally not recommended. A number of recommendations have been published seeking to address potential hypocalcemia during massive transfusion of citrated blood; however, many practitioners recommend replacement only as guided by clinical evidence of hypocalcemia and/or serial monitoring of ionized calcium.
Hypocalcemic tetany: I.V.: 1-3 g/dose may be administered until therapeutic response occurs
Magnesium intoxication or cardiac arrest in the presence of hyperkalemia or hypocalcemia: I.V.: 500-800 mg/dose (maximum: 3 g/dose)
Maintenance electrolyte requirements for TPN: I.V.: Daily requirements: 1.7-3.4 g/1000 kcal/24 hours
Calcium channel blocker overdose (unlabeled use): I.V. infusion: 10% solution: 0.6-1.2 mL/kg/hour or I.V. 0.2-0.5 ml/kg every 15-20 minutes for 4 doses (maximum: 2-3 g/dose). In life-threatening situations, 1 g has been given every 1-10 minutes until clinical effect is achieved (case reports of resistant hypotension reported use of 12-18 g total).
Adequate Intake (as elemental calcium):
0-6 months: 210 mg/day
7-12 months: 270 mg/day
1-3 years: 500 mg/day
4-8 years: 800 mg/day
9-18 years: 1300 mg/day
Dosage note: Calcium chloride has 3 times more elemental calcium than calcium gluconate. Calcium chloride is 27% elemental calcium; calcium gluconate is (9% elemental calcium). One gram of calcium chloride is equal to 270 mg of elemental calcium; 1 gram of calcium gluconate is equal to 90 mg of elemental calcium. The following dosages are expressed in terms of the calcium gluconate salt based on a solution concentration of 100 mg/mL (10%) containing 0.465 mEq (9.3 mg)/mL elemental calcium:
Hypocalcemia:
I.V.:
Neonates: 200-800 mg/kg/day as a continuous infusion or in 4 divided doses (maximum: 1 g/dose)
Infants and Children: 200-500 mg/kg/day as a continuous infusion or in 4 divided doses (maximum: 2-3 g/dose)
Oral: Children: 200-500 mg/kg/day divided every 6 hours
Hypocalcemia secondary to citrated blood infusion: I.V.: Neonates, Infants, and Children: Give 98 mg (0.45 mEq elemental calcium) for each 100 mL citrated blood infused.
Note: Routine administration of calcium, in the absence of signs/symptoms of hypocalcemia, is generally not recommended. A number of recommendations have been published seeking to address potential hypocalcemia during massive transfusion of citrated blood; however, many practitioners recommend replacement only as guided by clinical evidence of hypocalcemia and/or serial monitoring of ionized calcium.
Hypocalcemic tetany: I.V.: Infants and Children: 100-200 mg/kg/dose over 5-10 minutes; may repeat every 6-8 hours or follow with an infusion of 500 mg/kg/day
Magnesium intoxication or cardiac arrest in the presence of hyperkalemia or hypocalcemia: I.V.: Infants and Children: 60-100 mg/kg/dose (maximum: 3 g/dose)
Refer to adult dosing.
Clcr <25 mL/minute: Dosage adjustments may be necessary depending on the serum calcium levels.
Excipient information presented when available (limited, particularly for generics); consult specific product labeling. [DSC] = Discontinued product
Capsule, oral:
Cal-G: 700 mg [gluten free; equivalent to elemental calcium 65 mg]
Cal-GLU™: 515 mg [dye free, sugar free; equivalent to elemental calcium 50 mg]
Injection, solution [preservative free]: 10% (10 mL, 50 mL, 100 mL) [equivalent to elemental calcium 9.3 mg (0.465 mEq)/mL]
Powder, oral: (480 g)
Tablet, oral: 500 mg [equivalent to elemental calcium 45 mg], 648 mg [equivalent to elemental calcium 60 mg], 972 mg [DSC] [equivalent to elemental calcium 90 mg]
Yes
Not for I.M. or SubQ administration. For I.V. administration only; administer slowly (∼1.5 mL calcium gluconate 10% per minute) through a small needle into a large vein in order to avoid too rapid increased in serum calcium and extravasation.
Extravasation treatment example: Hyaluronidase: Add 1 mL NS to 150 unit vial to make 150 units/mL of concentration; mix 0.1 mL of above with 0.9 mL NS in 1 mL syringe to make final concentration = 15 units/mL
Stable in D5LR, D5NS, D5W, D10W, D20W, LR, NS; incompatible in fat emulsion 10%.
Y-site administration: Compatible: Aldesleukin, allopurinol, amifostine, aztreonam, cefazolin, cefepime, ciprofloxacin, cisatracurium, cladribine, dobutamine, docetaxel, doxorubicin liposome, enalaprilat, epinephrine, etoposide, famotidine, filgrastim, gatifloxacin, gemcitabine, granisetron, heparin with hydrocortisone sodium succinate, labetalol, linezolid, melphalan, midazolam, milrinone, piperacillin/tazobactam, potassium chloride, prochlorperazine edisylate, propofol, remifentanil, sargramostim, tacrolimus, teniposide, thiotepa, tolazoline, vinorelbine, vitamin B complex with C. Incompatible: Amphotericin B cholesteryl sulfate complex, fluconazole, indomethacin. Variable (consult detailed reference): Ampicillin, meropenem.
Compatibility in syringe: Incompatible: Metoclopramide.
Compatibility when admixed: Compatible: Amikacin, aminophylline, ascorbic acid injection, bretylium, chloramphenicol, corticotropin, dimenhydrinate, furosemide, heparin, hydrocortisone sodium succinate, lidocaine, magnesium sulfate, norepinephrine, penicillin G potassium, penicillin G sodium, phenobarbital, potassium chloride, tobramycin, vancomycin, verapamil, vitamin B complex with C. Incompatible: Amphotericin B, cefamandole, cefazolin, clindamycin, dobutamine, floxacillin, methylprednisolone sodium succinate. Variable (consult detailed reference): Folic acid, potassium phosphate, prochlorperazine edisylate, sodium bicarbonate; maximum concentration in parenteral nutrition solutions is variable depending upon concentration and solubility.
Treatment and prevention of hypocalcemia; treatment of tetany, cardiac disturbances of hyperkalemia, cardiac resuscitation when epinephrine fails to improve myocardial contractions, hypocalcemia; calcium supplementation; hydrofluoric acid (HF) burns
Calcium channel blocker overdose
Frequency not defined.
I.V.:
Cardiovascular: Arrhythmia, bradycardia, cardiac arrest, hypotension, vasodilation, and syncope may occur following rapid I.V. injection
Central nervous system: Sense of oppression
Gastrointestinal: Chalky taste
Local: Abscess and necrosis following I.M. administration
Neuromuscular & skeletal: Tingling sensation
Miscellaneous: Heat waves
Postmarketing and/or case reports: Calcinosis cutis
Oral: Gastrointestinal: Constipation
Hypersensitivity to calcium gluconate or any component of the formulation; ventricular fibrillation during cardiac resuscitation; digitalis toxicity or suspected digoxin toxicity; hypercalcemia
Concerns related to adverse effects:
• Cardiac arrest: May produce cardiac arrest.
• Gastrointestinal effects: Constipation, bloating, and gas are common with oral calcium supplements (especially carbonate salt).
Disease-related concerns:
• Acidosis: Use with caution in patients with respiratory acidosis, renal impairment, or respiratory failure; acidifying effect of calcium chloride may potentiate acidosis.
• Hyperphosphatemia: Use with caution in patients with severe hyperphosphatemia.
• Kidney stones (calcium-containing): Use caution when administering calcium supplements to patients with a history of kidney stones.
• Renal impairment: Use with caution in patients with renal failure to avoid hypercalcemia; frequent monitoring of serum calcium and phosphorus is necessary.
Concurrent drug therapy issues:
• Digitalis: Use with caution in digitalized patients; hypercalcemia may precipitate cardiac arrhythmias.
• Minerals/other oral drugs: Calcium administration interferes with absorption of some minerals and drugs; use with caution.
• Vitamin D: It is recommended to concomitantly administer vitamin D for optimal calcium absorption.
Dosage form specific issues:
• Absorption: Taking oral calcium (≤500 mg) with food improves absorption.
• Aluminum: Solutions may contain aluminum; toxic levels may occur following prolonged administration in premature neonates or patients with renal impairment.
• I.V. administration: For I.V. use only; do not inject SubQ or I.M. Avoid too rapid I.V. administration and avoid extravasation.
Bisphosphonate Derivatives: Calcium Salts may decrease the serum concentration of Bisphosphonate Derivatives. Management: Avoid administration of oral calcium supplements within: 2 hours before or after tiludronate/clodronate/etidronate; 60 minutes after ibandronate; or 30 minutes after alendronate/risedronate.Exceptions: Pamidronate; Zoledronic Acid.Risk D: Consider therapy modification
Calcium Acetate: Calcium Salts may enhance the adverse/toxic effect of Calcium Acetate. Risk X: Avoid combination
Calcium Channel Blockers: Calcium Salts may diminish the therapeutic effect of Calcium Channel Blockers. Risk C: Monitor therapy
CefTRIAXone: Calcium Salts (Intravenous) may enhance the adverse/toxic effect of CefTRIAXone. Ceftriaxone binds to calcium forming an insoluble precipitate. Management: Use of ceftriaxone with calcium-containing solutions within 48 hours of one another is contraindicated in neonates (28 days of age or younger). In older patients, flush lines with compatible fluid between administration.Risk D: Consider therapy modification
DOBUTamine: Calcium Salts may diminish the therapeutic effect of DOBUTamine. Risk C: Monitor therapy
Eltrombopag: Calcium Salts may decrease the serum concentration of Eltrombopag. Management: Separate administration of eltrombopag and any polyvalent cation (e.g., calcium-containing products) by at least 4 hours.Risk D: Consider therapy modification
Estramustine: Calcium Salts may decrease the absorption of Estramustine. Risk D: Consider therapy modification
Phosphate Supplements: Calcium Salts may decrease the absorption of Phosphate Supplements. Exceptions: Potassium Phosphate.Risk D: Consider therapy modification
Quinolone Antibiotics: Calcium Salts may decrease the absorption of Quinolone Antibiotics. Of concern only with oral administration of both agents. Exceptions: Moxifloxacin; Moxifloxacin (Systemic).Risk D: Consider therapy modification
Tetracycline Derivatives: Calcium Salts may decrease the serum concentration of Tetracycline Derivatives. Management: If coadministration of oral calcium with oral tetracyclines can not be avoided, consider separating administration of each agent by several hours.Risk D: Consider therapy modification
Thiazide Diuretics: May decrease the excretion of Calcium Salts. Continued concomitant use can also result in metabolic alkalosis.Risk C: Monitor therapy
Thyroid Products: Calcium Salts may diminish the therapeutic effect of Thyroid Products. Management: Separate the doses of the thyroid product and the oral calcium supplement by at least 4 hours.Risk D: Consider therapy modification
Trientine: Calcium Salts may decrease the serum concentration of Trientine. Trientine may decrease the serum concentration of Calcium Salts. Risk D: Consider therapy modification
Vitamin D Analogs: Calcium Salts may enhance the adverse/toxic effect of Vitamin D Analogs. Risk C: Monitor therapy
C (show table)
Reproduction studies have not been completed.
Enters breast milk
Endogenous calcium is excreted in breast milk.
Serum calcium: 8.4-10.2 mg/dL: Monitor plasma calcium levels if using calcium salts as electrolyte supplements for deficiency
Due to a poor correlation between the serum ionized calcium (free) and total serum calcium, particularly in states of low albumin or acid/base imbalances, direct measurement of ionized calcium is recommended
In low albumin states, the corrected total serum calcium may be estimated by: Corrected total calcium = total serum calcium + 0.8 (4.0 - measured serum albumin)
As dietary supplement, used to prevent or treat negative calcium balance; in osteoporosis, it helps to prevent or decrease the rate of bone loss. The calcium in calcium salts moderates nerve and muscle performance and allows normal cardiac function.
Absorption: Requires vitamin D; calcium is absorbed in soluble, ionized form; solubility of calcium is increased in an acid environment
Distribution: Primarily in bones and teeth; crosses placenta; enters breast milk
Protein binding: Primarily albumin
Excretion: Primarily feces (as unabsorbed calcium); urine (20%)