Dosage Forms
Excipient information presented when available (limited, particularly for generics); consult specific product labeling. [DSC] = Discontinued product
Syrup, Oral:
Calcionate: 1.8 g/5 mL (473 mL [DSC]) [fruit flavor]
Pharmacology
Mechanism of Action
As dietary supplement, used to prevent or treat negative calcium balance. The calcium in calcium salts moderates nerve and muscle performance and allows normal cardiac function.
Pharmacokinetics/Pharmacodynamics
Absorption
Minimal unless chronic, high doses; absorption predominantly in the duodenum and dependent on calcitriol and vitamin D; mean absorption of calcium intake varies with age (infants 60%, prepubertal children 28%, pubertal children 34%, adults 25%); during pregnancy, calcium absorption doubles; calcium is absorbed in soluble, ionized form; solubility of calcium is increased in an acid environment (IOM 2011); decreased absorption occurs in patients with achlorhydria, renal osteodystrophy, steatorrhea, or uremia
Distribution
Primarily in bones, teeth (IOM 2011)
Excretion
Primarily feces (75%; as unabsorbed calcium); urine (22%) (IOM 2011)
Protein Binding
~40%, primarily to albumin (Wills 1971)
Use: Labeled Indications
Dietary supplement
Dosage and Administration
Dosing: Adult
Dietary supplement: Oral: Note: Each 5 mL contains elemental calcium 115 mg: 15 mL 3 times daily or 15 mL 4 times daily (pregnancy/lactating)
Dosing: Geriatric
Refer to adult dosing.
Dosing: Pediatric
Calcium dietary supplement: Dosage below based on product containing: 1.8 g calcium glubionate/5 mL (115 mg elemental calcium/5 mL)
Infants: 5 mL 5 times a day; may mix with juice or formula
Children <4 years: 10 mL 3 times a day
Children ≥4 years and Adolescents: 15 mL 3 times a day
Hypocalcemia: Dose depends on clinical condition and serum calcium concentration:
Dose expressed as elemental calcium: Infants and Children: 45 to 65 mg/kg/day in 4 divided doses (Nelson 1996)
Dose expressed as calcium glubionate: Infants and Children: 600 to 2,000 mg/kg/day in 4 divided doses up to a maximum of 9 g/day
Rickets (due to vitamin D deficiency); treatment: Limited data available: Infants and Children: Dose expressed as elemental calcium: Oral: 30 to 75 mg/kg/day in 3 divided doses; begin at higher end of range and titrate downward over 2 to 4 weeks (Misra 2008)
Administration
Take with a full glass of water or juice, 1-3 hours after meals and other medications, and 1-2 hours before any approved iron supplements.
Dietary Considerations
Should be taken before meals to enhance absorption. May decrease iron absorption so should be administered 1-2 hours before or after iron supplementation. Limit intake of bran, foods high in oxalates, or whole grain cereals which may decrease calcium absorption.
Dietary reference intake for calcium (IOM 2011):
0 to <6 months: Adequate intake: 200 mg elemental calcium daily
6 to 12 months: Adequate intake: 260 mg elemental calcium daily
1 to 3 years: RDA: 700 mg elemental calcium daily
4 to 8 years: RDA: 1,000 mg elemental calcium daily
9 to 18 years: RDA: 1,300 mg elemental calcium daily
19 to 50 years: RDA: 1,000 mg elemental caclium daily
Females ≥51 years: RDA: 1,200 mg elemental calcium daily
Males: 51 to 70 years: RDA: 1,000 mg elemental calcium daily; >70 years: RDA: 1,200 mg elemental calcium daily
Pregnancy/Lactating: RDA: Requirements are the same as in nonpregnant or nonlactating females
Storage
Store at room temperature.
Drug Interactions
Alpha-Lipoic Acid: Calcium Salts may decrease the absorption of Alpha-Lipoic Acid. Alpha-Lipoic Acid may decrease the absorption of Calcium Salts. Consider therapy modification
Baloxavir Marboxil: Polyvalent Cation Containing Products may decrease the serum concentration of Baloxavir Marboxil. Avoid combination
Bictegravir: Calcium Salts may decrease the serum concentration of Bictegravir. Management: Bictegravir, emtricitabine, and tenofovir alafenamide can be administered with calcium salts under fed conditions, but coadministration with or 2 hours after a calcium salt is not recommended under fasting conditions. Consider therapy modification
Bisphosphonate Derivatives: Polyvalent Cation Containing Products may decrease the serum concentration of Bisphosphonate Derivatives. Management: Avoid administration of oral medications containing polyvalent cations within: 2 hours before or after tiludronate/clodronate/etidronate; 60 minutes after oral ibandronate; or 30 minutes after alendronate/risedronate. Exceptions: Pamidronate; Zoledronic Acid. Consider therapy modification
Calcium Acetate: Calcium Salts may enhance the adverse/toxic effect of Calcium Acetate. Avoid combination
Calcium Channel Blockers: Calcium Salts may diminish the therapeutic effect of Calcium Channel Blockers. Monitor therapy
Cardiac Glycosides: Calcium Salts may enhance the arrhythmogenic effect of Cardiac Glycosides. Monitor therapy
Deferiprone: Polyvalent Cation Containing Products may decrease the serum concentration of Deferiprone. Management: Separate administration of deferiprone and oral medications or supplements that contain polyvalent cations by at least 4 hours. Consider therapy modification
DOBUTamine: Calcium Salts may diminish the therapeutic effect of DOBUTamine. Monitor therapy
Dolutegravir: Calcium Salts may decrease the serum concentration of Dolutegravir. Management: Administer dolutegravir at least 2 hours before or 6 hours after oral calcium. Administer dolutegravir/rilpivirine at least 4 hours before or 6 hours after oral calcium salts. Alternatively, dolutegravir and oral calcium can be taken together with food. Consider therapy modification
Eltrombopag: Polyvalent Cation Containing Products may decrease the serum concentration of Eltrombopag. Management: Administer eltrombopag at least 2 hours before or 4 hours after oral administration of any polyvalent cation containing product. Consider therapy modification
Estramustine: Calcium Salts may decrease the absorption of Estramustine. Consider therapy modification
Multivitamins/Fluoride (with ADE): May increase the serum concentration of Calcium Salts. Calcium Salts may decrease the serum concentration of Multivitamins/Fluoride (with ADE). More specifically, calcium salts may impair the absorption of fluoride. Management: Avoid eating or drinking dairy products or consuming vitamins or supplements with calcium salts one hour before or after of the administration of fluoride. Consider therapy modification
Multivitamins/Minerals (with ADEK, Folate, Iron): May increase the serum concentration of Calcium Salts. Monitor therapy
PenicillAMINE: Polyvalent Cation Containing Products may decrease the serum concentration of PenicillAMINE. Management: Separate the administration of penicillamine and oral polyvalent cation containing products by at least 1 hour. Consider therapy modification
Phosphate Supplements: Calcium Salts may decrease the absorption of Phosphate Supplements. Management: This applies only to oral phosphate and calcium administration. Administering oral phosphate supplements as far apart from the administration of an oral calcium salt as possible may be able to minimize the significance of the interaction. Exceptions: Sodium Glycerophosphate Pentahydrate. Consider therapy modification
Quinolones: Calcium Salts may decrease the absorption of Quinolones. Of concern only with oral administration of both agents. Exceptions: LevoFLOXacin (Oral Inhalation); Moxifloxacin (Systemic). Consider therapy modification
Raltegravir: Polyvalent Cation Containing Products may decrease the serum concentration of Raltegravir. Management: Administer raltegravir 2 hours before or 6 hours after administration of the polyvalent cations. Dose separation may not adequately minimize the significance of this interaction. Consider therapy modification
Strontium Ranelate: Calcium Salts may decrease the serum concentration of Strontium Ranelate. Management: Separate administration of strontium ranelate and oral calcium salts by at least 2 hours in order to minimize this interaction. Consider therapy modification
Tetracyclines: Calcium Salts may decrease the serum concentration of Tetracyclines. Management: If coadministration of oral calcium with oral tetracyclines can not be avoided, consider separating administration of each agent by several hours. Exceptions: Eravacycline. Consider therapy modification
Thiazide and Thiazide-Like Diuretics: May decrease the excretion of Calcium Salts. Continued concomitant use can also result in metabolic alkalosis. 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. Consider therapy modification
Trientine: Polyvalent Cation Containing Products may decrease the serum concentration of Trientine. Management: Avoid concomitant administration of trientine and oral products that contain polyvalent cations. If oral iron supplements are required, separate the administration by 2 hours. If other oral polyvalent cations are needed, separate administration by 1 hour. Consider therapy modification
Vitamin D Analogs: Calcium Salts may enhance the adverse/toxic effect of Vitamin D Analogs. Monitor therapy
Test Interactions
Decreased magnesium
Adverse Reactions
Frequency not defined. Symptoms reported with hypercalcemia.
Endocrine & metabolic: Increased thirst
Gastrointestinal: Abdominal pain, anorexia, constipation, nausea, vomiting, xerostomia
Renal: Polyuria
Warnings/Precautions
Concerns related to adverse effects:
- Gastrointestinal effects: Constipation, bloating, and gas are common with calcium supplements (especially carbonate salt).
Disease-related concerns:
- Achlorhydria: Calcium absorption is impaired in achlorhydria; common in elderly, use an alternate salt (eg, citrate) and administer with food.
- Hypoparathyroid disease: Hypercalcemia and hypercalciuria are most likely to occur in hypoparathyroid patients receiving high doses of vitamin D.
- Kidney stones (calcium-containing): Use caution when administering calcium supplements to patients with a history of kidney stones.
Concurrent drug therapy issues:
- 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.
Other warnings/precautions:
- Absorption: Taking calcium (≤500 mg) with food improves absorption.
- Appropriate product selection: Multiple salt forms of calcium exist; close attention must be paid to the salt form when ordering and administering calcium; incorrect selection or substitution of one salt for another without proper dosage adjustment may result in serious over or under dosing.
Pregnancy
Pregnancy Considerations
Calcium crosses the placenta. Intestinal absorption of calcium increases during pregnancy. The amount of calcium reaching the fetus is determined by maternal physiological changes. Calcium requirements are the same in pregnant and nonpregnant females (IOM, 2011).
Patient Education
- Discuss specific use of drug and side effects with patient as it relates to treatment. (HCAHPS: During this hospital stay, were you given any medicine that you had not taken before? Before giving you any new medicine, how often did hospital staff tell you what the medicine was for? How often did hospital staff describe possible side effects in a way you could understand?)
- Patient may experience abdominal pain or passing gas. Have patient report immediately to prescriber severe constipation, severe nausea, severe vomiting, or confusion (HCAHPS).
- Educate patient about signs of a significant reaction (eg, wheezing; chest tightness; fever; itching; bad cough; blue skin color; seizures; or swelling of face, lips, tongue, or throat). Note: This is not a comprehensive list of all side effects. Patient should consult prescriber for additional questions.
Intended Use and Disclaimer: Should not be printed and given to patients. This information is intended to serve as a concise initial reference for healthcare professionals to use when discussing medications with a patient. You must ultimately rely on your own discretion, experience and judgment in diagnosing, treating and advising patients.
