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GeneraI
Pronunciation
(KAL see um GLOO koe nate)
Brand Names: U.S.
Cal-G [OTC] [DSC]
Cal-GLU [OTC]
PharmacoIogic Category
Calcium Salt
Electrolyte Supplement, Oral
Electrolyte Supplement, Parenteral
Indications
Use: LabeIed Indications
.V.: Treatment of hypocalcemia and conditions secondary to hypocalcemia (eg, tetany, seizures,
arrhythmias); treatment of cardiac disturbances secondary to hyperkalemia; adjunctive treatment of
rickets, osteomalacia, and magnesium sulfate overdose; decrease capillary permeability in allergic
conditions, nonthrombocytopenic purpura, and exudative dermatoses (eg, dermatitis herpetiformis,
pruritus secondary to certain drugs)
Oral: Dietary calcium supplementation
Use: UnIabeIed
Calcium channel blocker overdose; treatment of hydrofluoric acid exposure
Contraindications
Ventricular fibrillation; hypercalcemia; concomitant use of .V. calcium gluconate and ceftriaxone in neonates
(risk of precipitation of calcium-ceftriaxone)
Dosing and Administration
Dosage
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Note: One gram of calcium gluconate salt is equal to 93 mg of elemental calcium.
Dosages are expressed in terms of the caIcium gIuconate saIt (unIess otherwise specified as
eIementaI caIcium). Dosages expressed in terms of the caIcium gIuconate saIt are based on a
soIution concentration of 100 mg/mL (10%) containing 0.465 mEq (9.3 mg)/mL eIementaI caIcium,
except where noted.
Dietary Reference Intake for CaIcium: Oral: Note: Expressed in terms of elemental calcium:
1-6 months: Adequate intake: 200 mg eIementaI caIcium daily
7-12 months: Adequate intake: 260 mg eIementaI caIcium daily
1-3 years: RDA: 700 mg eIementaI caIcium daily
4-8 years: RDA: 1000 mg eIementaI caIcium daily
9-18 years: RDA: 1300 mg eIementaI caIcium daily
Adults, Females/Males: RDA:
19-50 years: 1000 mg eIementaI caIcium daily
<51 years, females: 1200 mg eIementaI caIcium daily
51-70 years, males: 1000 mg eIementaI caIcium daily
>70 years, males: 1200 mg eIementaI caIcium daily
Females: Pregnancy/Lactating: RDA: Requirements are the same as in nonpregnant or nonlactating
females
Hypocalcemia: .V.:
nfants and Children: 200-500 mg/kg/day as a continuous infusion or in 4 divided doses (maximum:
2000-3000 mg/dose)
Adults:
Mild (ionized calcium: 4-5 mg/dL [1-1.2 mmol/L]): 1000-2000 mg 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]): 4000 mg
over 4 hours (French, 2012)
Severe symptomatic (eg, seizure, tetany): 1000-2000 mg over 10 minutes; repeat every 60 minutes
until symptoms resolve (French, 2012)
Note: Repeat ionized calcium measurement 6-10 hours after completion of administration.
Check for hypomagnesemia and correct if present. Consider continuous infusion if
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hypocalcemia is likely to recur due to ongoing losses (French, 2012).
Continuous infusion: 5-20 mg/kg/hour (Pai, 2011)
Cardiac arrest or cardiotoxicity in the presence of hyperkalemia, hypocalcemia, or hypermagnesemia: .V.:
nfants and Children: 60-100 mg/kg/dose (maximum: 3000 mg/dose) (Hegenbarth, 2008)
Adults: 1500-3000 mg over 2-5 minutes (Vanden Hoek, 2010)
Note: Routine use in cardiac arrest is not recommended due to the lack of improved survival (Kleinman,
2010; Neumar, 2010):
Maintenance electrolyte requirements for parenteral nutrition: .V. (Mirtallo, 2004): Note: Expressed in terms
of eIementaI caIcium:
nfants and Children (<50 kg): 0.5-4 mEq eIementaI caIcium/kg/day
Adults: 10-20 mEq eIementaI caIcium daily
Calcium channel blocker overdose (unlabeled use): Hypotension/conduction disturbances:
Children: .V., .O.: 60 mg/kg/dose administered over 30-60 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.
Adults: .V.: 60-120 mg/kg/hour (Salhanick, 2003) or 60 mg/kg/dose over 5 minutes (maximum:
3000-6000 mg/dose) every 10-20 minutes; may repeat for 3-4 additional doses (Vanden Hoek,
2010; DeWitt, 2004). n life-threatening situations, 1000 mg has been administered every 2-3
minutes until clinical effect is achieved (Buckley, 1994). n one report, 18 g was administered over a
3-hour period (Luscher, 1994).
Hydrofluoric acid burns, treatment (unlabeled route/use): Children and Adults:
SubQ (unlabeled route/use): 5% to 10% solution: 0.5 mL/cm
2
of burned tissue (Dibbell, 1970; Hatzifotis,
2004; Kirkpatrick, 1995; Krenzelok, 1999). nfiltration 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).
ntra-arterial (unlabeled route/use): Add 10 mL of a 10% solution to 50 mL of D
5
W. nfuse 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
shouId be used onIy by those accustomed to this technique. Extreme care shouId be taken
to avoid the extravasation. A poison information center or clinical toxicologist should be consulted
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prior to implementation.
nhalation (unlabeled route/use): 2.5% nebulization solution: Mix 1 mL of 10% calcium gluconate solution
with 4 mL NS to make a 2.5% solution and administer via nebulization (Hatzifotis, 2004).
Dosing adjustment in renaI impairment: No initial dosage adjustment necessary; however, accumulation
may occur with renal impairment and subsequent doses may require adjustment based on serum calcium
concentrations.
Dosing adjustment in hepatic impairment: No initial dosage adjustment necessary; subsequent doses
should be guided by serum calcium concentrations. n patients in the anhepatic stage of liver
transplantation, equal rapid increases in ionized concentrations occur suggesting that calcium gluconate
does not require hepatic metabolism for release of ionized calcium (Martin, 1990).
Reconstitution
nhalation: Treatment of hydrofluoric acid burns (unlabeled use): Mix 1 mL of 10% calcium gluconate solution
with 4 mL NS to make a 2.5% solution.
Administration
.V.: Administer slowly (~1.5 mL calcium gluconate 10% per minute; not to exceed 200 mg/minute except in
emergency situations) through a small needle into a large vein in order to avoid too rapid increases in the
serum calcium and extravasation. Not for .M. administration; not for routine SubQ administration
(exception: treatment of hydrofluoric acid burns [unlabeled route/use]).
Treatment of hydrofluoric acid burns (unlabeled use):
SubQ infiltration (unlabeled 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 (unlabeled 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 shouId be
used onIy by those accustomed to this technique. Care shouId 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.
CompatibiIity
Stable in D
5
LR, D
5
1
/
4
NS, D
5
1
/
2
NS, D
5
NS, D
5
R, D
5
W, D
10
W, D
20
W, LR, NS, R, SL; incompatibIe in fat
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emulsion 10%.
Y-site administration: IncompatibIe with amphotericin B cholesteryl sulfate complex, fluconazole,
indomethacin, lansoprazole, pemetrexed.
Storage
.V.: Store at 20C to 25C (68F to 77F); excursions permitted to 15C to 30C (59F to 86F). f
crystallization has occurred, place vial in a warm water bath for 15-30 minutes and occasionally shake to
dissolve; cool to body temperature before use.
Usual concentrations: 1 g/100 mL D
5
W or NS; 2 g/100 mL D
5
W or NS.
Maximum concentration in parenteral nutrition solutions is variable depending upon concentration and solubility
(consult detailed reference).
Dosage Forms/Strengths
Excipient information presented when available (limited, particularly for generics); consult specific product
labeling. [DSC] = Discontinued product
Capsule, oral:
Cal-G: 700 mg [DSC] [gluten free; equivalent to elemental calcium 65 mg]
Cal-GLU: 515 mg [dye free, sugar free; equivalent to elemental calcium 50 mg]
njection, 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]
Interactions
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 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
CefTRAXone: Calcium Salts (ntravenous) may enhance the adverse/toxic effect of CefTRAXone.
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). n older patients, flush lines with compatible fluid between administration. Consider
therapy modification
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Deferiprone: Calcium Salts 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
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. Consider therapy modification
Estramustine: Calcium Salts may decrease the absorption of Estramustine. Consider therapy modification
Multivitamins/Minerals (with ADEK, Folate, ron): May increase the serum concentration of Calcium Salts.
Monitor therapy
Phosphate Supplements: Calcium Salts may decrease the absorption of Phosphate Supplements.
Exceptions: Potassium Phosphate. 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 (Systemic). 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
Tetracycline Derivatives: Calcium Salts may decrease the serum concentration of Tetracycline Derivatives.
Management: f coadministration of oral calcium with oral tetracyclines can not be avoided, consider
separating administration of each agent by several hours. Consider therapy modification
Thiazide 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: Calcium Salts may decrease the serum concentration of Trientine. Trientine may decrease the
serum concentration of Calcium Salts. Consider therapy modification
Vitamin D Analogs: Calcium Salts may enhance the adverse/toxic effect of Vitamin D Analogs. Monitor
therapy
Lab Test Interferences
.V. administration may produce falsely decreased serum and urine magnesium concentrations
Adverse Reactions
Frequency not defined.
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.V.:
Cardiovascular (with rapid .V. injection): Arrhythmia, bradycardia, cardiac arrest, hypotension, syncope,
vasodilation
Central nervous system: Sense of oppression (with rapid .V. injection)
Endocrine & metabolic: Hypercalcemia
Gastrointestinal: Chalky taste
Neuromuscular & skeletal: Tingling sensation (with rapid .V. injection)
Miscellaneous: Heat waves (with rapid .V. injection)
Postmarketing and/or case reports: Calcinosis cutis
Oral: Gastrointestinal: Constipation
Warnings/Precautions
Concerns related to adverse effects:
Gastrointestinal 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:
Ceftriaxone: Ceftriaxone may complex with calcium causing precipitation. Fatal lung and kidney damage
associated with calcium-ceftriaxone precipitates has been observed in premature and term
neonates. Due to reports of precipitation reaction in neonates, do not coadminister ceftriaxone with
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calcium-containing solutions, even via separate infusion lines/sites or at different times in any
neonate. Ceftriaxone should not be administered simultaneously with any calcium-containing solution
via a Y-site in any patient. However, ceftriaxone and calcium-containing solutions may be
administered sequentially of one another for use in patients other than neonates if infusion lines are
thoroughly flushed (with a compatible fluid) between infusions.
Digoxin: 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: t 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.
.V. administration: Avoid too rapid .V. administration (do not exceed 200 mg/minute except in
emergency situations); may result in vasodilation, hypotension, bradycardia, arrhythmias, and
cardiac arrest. Avoid extravasation; adverse events from extravasation can be devastating (eg,
profound tissue necrosis). Monitor the .V. site closely.
Pregnancy Risk Factor
C
Pregnancy Considerations
Animal reproduction studies have not been conducted. 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 (OM, 2011). nformation related to use as an antidote in pregnancy is
limited. n general, medications used as antidotes should take into consideration the health and prognosis of
the mother (Bailey, 2003).
Lactation
Enters breast milk
Actions
PharmacoIogy
Moderates nerve and muscle performance via action potential threshold regulation.
n 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.
Absorption
Oral: Requires vitamin D; calcium is absorbed in soluble, ionized form; solubility of calcium is increased in an
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acid environment
Excretion
Primarily feces (as unabsorbed calcium salts); urine (20%)
Protein Binding
~40%, primarily to albumin (Wills, 1971)
Patient and FamiIy Education
Discuss specific use of drug and side effects with patient as it relates to treatment. Patient may experience
nausea, constipation, or injection site irritation. Have patient report immediately to prescriber illogical thinking
or rash. 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.
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