Calcium Gluconate

Dosage Forms

Excipient information presented when available (limited, particularly for generics); consult specific product labeling. [DSC] = Discontinued product

Capsule, Oral [preservative free]:

Cal-Glu: 500 mg [dye free]

Solution, Intravenous:

Generic: 10% (10 mL [DSC], 50 mL [DSC], 100 mL [DSC]); 3% in NaCl 0.9% (100 mL [DSC])

Solution, Intravenous [preservative free]:

Generic: 10% (10 mL, 50 mL, 100 mL); Calcium gluconate 1 g/50 mL in NaCl 0.675% (50 mL); Calcium gluconate 2 g/100 mL in NaCl 0.675% (100 mL)

Tablet, Oral:

Generic: 50 mg, 500 mg [DSC]

Pharmacology

Mechanism of Action

Moderates nerve and muscle performance via action potential threshold regulation.

In hydrogen fluoride exposures, calcium gluconate provides a source of calcium ions to complex free fluoride ions and prevent or reduce toxicity; administration also helps to correct fluoride-induced hypocalcemia.

Pharmacokinetics/Pharmacodynamics

Absorption

Oral: Minimal unless chronic, high doses are given; 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 acidic environment (IOM 2011); decreased absorption occurs in patients with achlorhydria, renal osteodystrophy, steatorrhea, or uremia

Distribution

Primarily in skeleton (99%)

Excretion

Primarily feces (75%; as unabsorbed calcium salts); urine (20%) (IOM 2011)

Protein Binding

~40%, primarily to albumin

Use: Labeled Indications

Dietary supplement (oral only): Dietary calcium supplementation

Hypocalcemia (IV only): Treatment of acute symptomatic hypocalcemia in adult and pediatric patients

Use: Off Label

Beta-blocker overdosecyes

Data from one human case report and an animal study suggest that calcium gluconate may be helpful in beta blocker overdose Love 1996, Pertoldi 1998. Clinical experience also suggests the utility of calcium gluconate in the treatment of beta-blocker overdose Kerns 2007.

Based on the American Heart Association (AHA) guideline for cardiopulmonary resuscitation and emergency cardiovascular care, calcium gluconate is a recommended treatment option in the setting of beta-blocker overdose (refractory to glucagon and high-dose inotropes/vasopressors).

Calcium channel blocker overdosecyes

Data from a limited number of patients suggest the use of calcium gluconate may be beneficial for the treatment of hemodynamically unstable calcium channel blocker overdose refractory to other treatments Perkins 1978, Ramoska 1993. Clinical experience also suggests the utility of calcium gluconate in the treatment of calcium channel blocker overdose Kerns 2007.

Based on the American Heart Association (AHA) Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care, the Experts Consensus Recommendations for the Management of Calcium Channel Blocker Poisoning in Adults, and the American College of Cardiology/American Heart Association/Heart Rhythm Society (ACC/AHA/HRS) Guideline on the evaluation and management of patients with bradycardia and cardiac conduction delay, calcium gluconate is an effective and recommended treatment option in the setting of calcium channel blocker overdose.

Hydrofluoric acid burnc

Data from a limited number of patients studied (case series) suggests that calcium gluconate may be beneficial for the treatment of patients having been exposed to and burned by hydrofluoric acid Dibbell 1970, Hatzifotis 2004. Clinical experience also suggests the utility of calcium gluconate in an algorithmic approach in the treatment of hydrofluoric acid burns Kirkpatrick 1995, Krenzelok 1999.

Contraindications

Hypercalcemia; concomitant use of IV calcium gluconate with ceftriaxone in neonates (≤28 days of age).

Dosage and Administration

Dosing: Adult

Note: One gram of calcium gluconate salt is equal to 93 mg of elemental calcium.

Dosages are expressed in terms of the calcium gluconate salt (unless otherwise specified as elemental calcium). Dosages expressed in terms of the calcium gluconate salt are based on a solution concentration of 100 mg/mL (10%) containing 0.465 mEq (9.3 mg)/mL elemental calcium, except where noted.

Beta-blocker overdose (off-label use): Based on limited data: IV: Initial: Using a 10% solution: 60 mg/kg over 5 to 10 minutes (maximum: 3 to 6 g/dose); may repeat every 10 to 20 minutes for 3 to 4 additional doses or initiate a continuous infusion of 60 to 120 mg/kg/hour titrated to improve hemodynamic response (AHA [Vanden Hoek 2010]; DeWitt 2004; Kerns 2007).

Calcium channel blocker overdose (off-label use): Based on limited data: IV: Initial: Using a 10% solution: 60 mg/kg over 5 to 10 minutes (maximum: 3 to 6 g/dose); may repeat every 10 to 20 minutes for 3 to 4 additional doses or initiate a continuous infusion of 60 to 120 mg/kg/hour titrated to improve hemodynamic response (ACC/AHA/HRS [Kusumoto 2018]; AHA [Vanden Hoek 2010]; DeWitt 2004; Kerns 2007; St-Onge 2017). Note: Some recommend maintaining serum ionized calcium at a goal of twice normal (Kerns 2007).

Cardiac arrest or cardiotoxicity in the presence of hyperkalemia, hypocalcemia, or hypermagnesemia: IV: 1.5 to 3 g over 2 to 5 minutes (Vanden Hoek 2010)

Note: Routine use in cardiac arrest is not recommended due to the lack of improved survival (Neumar 2010):

Hydrofluoric acid burns, treatment (off-label use):

SubQ (off-label): 5% to 10% solution: 0.5 mL/cm² of burned tissue (Dibbell 1970; Hatzifotis 2004; Kirkpatrick 1995; Krenzelok 1999). Infiltration should be carried 0.5 cm away from the margin of the injured tissue into the surrounding uninjured areas. Repeat if pain recurs. Local anesthesia may be required to perform procedure; pain resolution is the therapeutic endpoint and if a local anesthetic is utilized, it may be difficult to determine the success of therapy (Note: Never use calcium chloride for subcutaneous injection).

Intra-arterial (off-label): Add 10 mL of a 10% solution to 50 mL of D5W. Infuse over 4 hours into the artery that provides the vascular supply to the affected area (Hatzifotis 2004; Kirkpatrick 1995). Pain usually resolves by the end of the infusion; repeat if pain recurs. This intervention should be used only by those accustomed to this technique. Extreme care should be taken to avoid the extravasation. A poison information center or clinical toxicologist should be consulted prior to implementation.

Inhalation (off-label): 2.5% nebulization solution: Mix 1.5 mL of 10% calcium gluconate solution with 4.5 mL NS to make a 2.5% solution and administer via nebulization (Upfal 1990).

Hypocalcemia: IV:

Mild (ionized calcium: 4 to 5 mg/dL [1 to 1.2 mmol/L]): 1 to 2 g over 2 hours; asymptomatic patients may be given oral calcium (Ariyan 2004; French 2012).

Moderate to severe (without seizure or tetany; ionized calcium: <4 mg/dL [<1 mmol/L]): 4 g over 4 hours (French 2012)

Severe symptomatic (eg, seizure, tetany): 1 to 2 g over 10 minutes; repeat every 60 minutes until symptoms resolve (French 2012)

Note: Repeat ionized calcium measurement 6 to 10 hours after completion of administration. Check for hypomagnesemia and correct if present. Consider continuous infusion if hypocalcemia is likely to recur due to ongoing losses (French 2012).

Continuous infusion: 5 to 20 mg/kg/hour (Pai 2011); in patients with hypoparathyroidism, oral calcium and active vitamin D (ie, calcitriol) with or without ergocalciferol or cholecalciferol should be initiated as soon as is practical; IV calcium is generally tapered slowly while oral therapy is adjusted (Endocrine Society [Bilezikian 2016]).

Hypocalcemia induced by citrate-based replacement fluid during continuous renal replacement therapy (CRRT) (off-label dose): IV (administered via return line): Note: Prior to initiation of CRRT, check ionized calcium and administer calcium gluconate if <4 mg/dL (<1 mmol/L) until >4 mg/dL (>1 mmol/L). During CRRT, a continuous infusion sliding scale may be initiated (may use calcium gluconate 20 gram/1,000 mL NS or D5W solution). The following schema has been employed (Palsson 1999):

If ionized calcium is <3.6 mg/dL (<0.9 mmol/L): Notify nephrology.

If ionized calcium is 3.6 to 4 mg/dL (0.9 to 1 mmol/L): 1.4 g/hour

If ionized calcium is 4 to 4.4 mg/dL (1 to 1.1 mmol/L): 1.2 g/hour

If ionized calcium is 4.4 to 5.2 mg/dL (1.1 to 1.3 mmol/L): 1 g/hour

If ionized calcium is >5.2 mg/dL (>1.3 mmol/L): Notify nephrology.

Parenteral nutrition, maintenance requirement: IV: Note: Expressed in terms of elemental calcium: 10 to 20 mEq elemental calcium daily (ASPEN [Mirtallo 2004]). Adjust dose based on total or ionized calcium.

Dosing: Geriatric

Refer to adult dosing.

Dosing: Pediatric

Parenteral nutrition, maintenance calcium requirement (ASPEN [Mirtallo 2004]): Note: Dose expressed as elemental calcium: IV:

Infants and Children ≤50 kg: 0.5 to 4 mEq/kg/day as an additive to parenteral nutrition solution.

Children >50 kg and Adolescents: 10 to 20 mEq/day as an additive to parenteral nutrition solution.

Hypocalcemia: Dose depends on clinical condition and serum calcium concentration:

General dosing: Infants, Children, and Adolescents: Dose expressed as calcium gluconate: IV: 200 to 500 mg/kg/day as a continuous infusion or in 4 divided doses; maximum dose: Infants and Children: 1,000 mg/dose; Adolescents: 2,000 to 3,000 mg/dose (Edmondson 1990; Zhou 2009).

Symptomatic (ie, seizures, tetany): Infants, Children, and Adolescents: Dose expressed as calcium gluconate: IV: 100 to 200 mg/kg/dose over 5 to 10 minutes; usual adult dose: 1,000 to 2,000 mg/dose; may repeat after 6 hours or follow with a continuous infusion of 200 to 800 mg/kg/day (Edmondson 1990; Kelly 2013; Misra 2008; Nelson 1996; Zhou 2009).

Chronic therapy in asymptomatic patient: Infants and Children: Dose expressed as calcium gluconate: Oral: 500 mg/kg/day in divided doses every 4 to 8 hours (Nelson 1996); Note: In general, other oral calcium salts (eg, carbonate, glubionate) are a more preferable oral dosage form option in young pediatric patients; however, the 10% calcium gluconate injection may be given orally (Mimouni 1994).

Rickets (due to vitamin D deficiency); treatment: 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). Note: In general, other oral calcium salts (eg, carbonate, glubionate) are a more preferable oral dosage formulation option in young pediatric patients; however, the 10% calcium gluconate injection may be given orally (Mimouni 1994).

Cardiac arrest in the presence of hyperkalemia or hypocalcemia, hypermagnesemia, or calcium channel blocker toxicity: Infants, Children, and Adolescents: Dose expressed as calcium gluconate: IV, Intraosseous: 60 to 100 mg/kg/dose (maximum dose: 3,000 mg); may repeat in 10 minutes if necessary; if effective, consider IV infusion (Hegenbarth 2008). Note: Routine use in cardiac arrest is not recommended due to the lack of improved survival (PALS [Kleinman] 2010).

Calcium channel blocker toxicity; hypotension/conduction disturbances: Infants, Children, and Adolescents: Dose expressed in mg of calcium gluconate: IV, Intraosseous: 60 mg/kg/dose administered over 30 to 60 minutes (Hegenbarth 2008). Note: Calcium chloride may provide a more rapid increase of ionized calcium in critically ill children. Calcium gluconate may be substituted if calcium chloride is not available.

Hydrofluoric acid burns, treatment: Limited data available: Children and Adolescents:

SubQ: 5% to 10% solution: 0.5 mL/cm² of burned tissue (Dibbell 1970; Hatzifotis 2004; Kirkpatrick 1995; Krenzelok 1999). Infiltration should be carried 0.5 cm away from the margin of the injured tissue into the surrounding uninjured areas. Repeat if pain recurs. Local anesthesia may be required to perform procedure; pain resolution is the therapeutic endpoint and if a local anesthetic is utilized, it may be difficult to determine the success of therapy. Note: Never use calcium chloride for subcutaneous injection.

Intra-arterial: Add 10 mL of a 10% solution to 50 mL of D5W. Infuse over 4 hours into the artery that provides the vascular supply to the affected area (Hatzifotis 2004; Kirkpatrick 1995). Pain usually resolves by the end of the infusion; repeat if pain recurs. This intervention should be used only by those accustomed to this technique. Extreme care should be taken to avoid the extravasation. A poison information center or clinical toxicologist should be consulted prior to implementation.

Inhalation: 2.5% nebulization solution: Mix 1.5 mL of 10% calcium gluconate solution with 4.5 mL NS to make a 2.5% solution and administer via nebulization (Upfal 1990).

Reconstitution

IV: Observe the vial for the presence of particulates. If particulates are observed, place vial in a 60°C to 80°C water bath with occasional agitation until solution is clear; shake vigorously; cool to room temperature before use. Do not use vial if particulates do not dissolve. Prior to administration, dilute in D5W or NS and use immediately:

Bolus: Dilute to a concentration of 10 to 50 mg/mL.

Continuous infusion: Dilute to a concentration of 5.8 to 10 mg/mL.

Note: Usual concentrations: 1 g/100 mL D5W or NS; 2 g/100 mL D5W or NS. Maximum concentration in parenteral nutrition solutions is variable depending upon concentration and solubility (consult detailed reference).

Inhalation: Treatment of hydrofluoric acid burns (off-label use): Mix 1.5 mL of 10% calcium gluconate solution with 4.5 mL NS to make a 2.5% solution (Upfal 1990).

Administration

Oral: Administer with plenty of fluids with or following meals.

IV: For bolus or continuous infusion. Administer bolus slowly (not to exceed 200 mg/minute). For continuous infusions, adjust rate as needed based on serum calcium levels. Typical rates of administration may vary with indication; refer to institutional protocol. Not for IM administration.

Vesicant; ensure proper needle or catheter placement prior to and during IV infusion. Avoid extravasation.

Extravasation management: If extravasation occurs, stop infusion immediately and disconnect (leave needle/cannula in place); gently aspirate extravasated solution (do NOT flush the line).

Early/acute calcium extravasation: Initiate hyaluronidase antidote; remove needle/cannula; apply dry cold compresses; elevate extremity (Hurst 2004; Reynolds 2014).

Hyaluronidase: Intradermal or SubQ: Inject a total of 1 to 1.7 mL (15 units/mL) as five separate 0.2 to 0.3 mL injections (using a 25-gauge needle) into area of extravasation at the leading edge in a clockwise manner (MacCara 1983; Reynolds 2014; Zenk 1981). May also inject hyaluronidase through the catheter that caused the infiltration (Reynolds 2014).

Delayed calcium extravasation: Closely monitor site; most calcifications spontaneously resolve. However, if a severe manifestation of calcinosis cutis occurs, may initiate sodium thiosulfate antidote.

Sodium thiosulfate: IV: 12.5 g over 30 minutes; may increase gradually to 25 g 3 times per week; monitor for non-anion gap acidosis, hypocalcemia, severe nausea (Reynolds 2014).

Treatment of hydrofluoric acid burns (off-label use):

SubQ infiltration (off-label route): Using a 27- or 30-gauge needle, approach the wound from the distal point of injury and infiltrate directly into the affected dermis and subcutaneous tissue. The infiltration should be carried 0.5 cm away from the margin of the injured tissue into the surrounding uninjured areas (Dibbell 1970). Avoid excessive administration as it can cause compartment syndrome and further exacerbate tissue damage. Following subungual exposure, administer to the affected area via the lateral or volar route through the fat pad (under digital nerve block); administration may also require removal of the nailbed, splitting the distal nail from the nailbed, or trimming the nail to the nailbed to reach the affected area (Kirkpatrick 1995; Roberts 1989).

Intra-arterial (off-label route): Requires radiology to place an arterial catheter in an artery supplying blood to the area of exposure; infuse over four hours (Vance 1986). This intervention should be used only by those accustomed to this technique. Care should be taken to avoid the extravasation. A poison information center or clinical toxicologist should be consulted prior to implementation.

Inhalation: Dilute 10% calcium gluconate solution to a 2.5% solution and administer via nebulization.

Dietary Considerations

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 calcium 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

IV: Store intact vials at 20°C to 25°C (68°F to 77°F). Do not freeze. Discard unused portion within 4 hours after initial puncture.

Oral: Store at room temperature; consult product labeling for specific requirements.

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

CefTRIAXone: Calcium Salts (Intravenous) may enhance the adverse/toxic effect of CefTRIAXone. Ceftriaxone binds to calcium forming an insoluble precipitate. Management: Use of ceftriaxone is contraindicated in neonates (28 days of age or younger) who require (or are expected to require) treatment with IV calcium-containing solutions. In older patients, flush lines with compatible fluid between administration. Consider therapy modification

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

IV administration may produce falsely decreased serum and urine magnesium concentrations

Adverse Reactions

Frequency not defined:

Cardiovascular: Arrhythmia, bradycardia, cardiac arrest, decreased blood pressure, syncope, vasodilation

Central nervous system: Anxiety, feeling hot

Gastrointestinal: Unusual taste (chalky)

Neuromuscular & skeletal: Tingling sensation

Warnings/Precautions

Concerns related to adverse effects:

• Extravasation: Parenteral calcium is a vesicant; ensure proper catheter or needle position prior to and during infusion. Avoid extravasation; adverse events from extravasation can be devastating (eg, profound tissue necrosis). Monitor the IV site closely.
• GI effects: Constipation, bloating, and gas are common with oral calcium supplements (especially carbonate salt).

Disease-related concerns:

• Hyperphosphatemia: Use with caution in patients with severe hyperphosphatemia as elevated levels of phosphorus and calcium may result in soft tissue and pulmonary arterial calcium-phosphate precipitation.
• Hypokalemia: Use with caution in patients with severe hypokalemia as acute rises in serum calcium levels may result in life-threatening cardiac arrhythmias.
• Hypomagnesemia: Hypomagnesemia is a common cause of hypocalcemia; therefore, correction of hypocalcemia may be difficult in patients with concomitant hypomagnesemia. Evaluate serum magnesium and correct hypomagnesemia (if necessary), particularly if initial treatment of hypocalcemia is refractory.
• 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 chronic renal failure to avoid hypercalcemia; frequent monitoring of serum calcium and phosphorus is necessary.

Concurrent drug therapy issues:

• Drug-drug interactions: Potentially significant interactions may exist, requiring dose or frequency adjustment, additional monitoring, and/or selection of alternative therapy. Consult drug interactions database for more detailed information.

Dosage form specific issues:

• Aluminum: The parenteral product may contain aluminum; toxic aluminum concentrations may be seen with high doses, prolonged use, or renal dysfunction. Premature neonates are at higher risk due to immature renal function and aluminum intake from other parenteral sources. Parenteral aluminum exposure of >4 to 5 mcg/kg/day is associated with CNS and bone toxicity; tissue loading may occur at lower doses (Federal Register 2002). See manufacturer's labeling.
• 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.
• IV administration: Avoid too-rapid IV administration (do not exceed 200 mg/minute in adults and 100 mg/minute in pediatric patients); may result in vasodilation, hypotension, bradycardia, arrhythmias, syncope, and cardiac arrest. Safety for long-term use has not been established.
• Oral administration: Administering oral calcium with food and vitamin D will optimize calcium absorption.
• Tartrazine: Some products may contain tartrazine, which may cause allergic reactions in susceptible individuals.

Monitoring Parameters

IV: Serum calcium every 4 hours (during intermittent infusion) or every 1 to 4 hours (during continuous infusion); albumin, phosphate, and magnesium; vitals and ECG when appropriate. Monitor infusion site.

Calcium channel blocker overdose, beta-blocker overdose (off-label use): Monitor hemodynamic response; monitor serum ionized calcium levels every 30 minutes initially, then every 2 hours and maintain ionized calcium ~2 times the ULN; avoid severe hypercalcemia (ionized calcium levels >2 times ULN) (Kerns 2007).

Pregnancy

Pregnancy Considerations

Calcium crosses the placenta. 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). Information related to use as an antidote in pregnancy is limited. In general, medications used as antidotes should take into consideration the health and prognosis of the mother; antidotes should be administered to pregnant women if there is a clear indication for use and should not be withheld because of fears of teratogenicity (Bailey 2003). Medications used for the treatment of cardiac arrest in pregnancy are the same as in the non-pregnant woman. Doses and indications should follow current Advanced Cardiovascular Life Support guidelines. Appropriate medications should not be withheld due to concerns of fetal teratogenicity (Jeejeebhoy [AHA] 2015).

Patient Education

What is this drug used for?

• It is used to treat or prevent low calcium levels.
• It may be given to you for other reasons. Talk with the doctor.

Frequently reported side effects of this drug

• Constipation

Other side effects of this drug: Talk with your doctor right away if you have any of these signs of:

• High calcium like weakness, confusion, fatigue, headache, nausea and vomiting, constipation, or bone pain
• Flushing
• Severe dizziness
• Passing out
• Slow heartbeat
• Abnormal heartbeat
• Severe injection site pain, redness, burning, edema, or irritation
• Signs of a significant reaction like 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. Talk to your doctor if you have questions.

Consumer Information Use and Disclaimer: This information should not be used to decide whether or not to take this medicine or any other medicine. Only the healthcare provider has the knowledge and training to decide which medicines are right for a specific patient. This information does not endorse any medicine as safe, effective, or approved for treating any patient or health condition. This is only a brief summary of general information about this medicine. It does NOT include all information about the possible uses, directions, warnings, precautions, interactions, adverse effects, or risks that may apply to this medicine. This information is not specific medical advice and does not replace information you receive from the healthcare provider. You must talk with the healthcare provider for complete information about the risks and benefits of using this medicine.