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). In one report, 18 g was administered over a 3-hour period (Lüscher 1994). Note: Some recommend maintaining serum ionized calcium at a goal of twice normal (Kerns 2007).
Cardiac arrest or cardiotoxicity in the presence of 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 exposure, 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 1 g (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).
IV: (Bier block technique) (off label): 10% solution: Add 1.5 g (15 mL of a 10% solution) to 35 mL of NS and infuse over 2 minutes using a Bier block technique (Zhang 2014).
Hydrofluoric acid exposure, hypocalcemia prevention and treatment (off-label use): Note: Profound and precipitous hypocalcemia may occur after exposure to higher hydrofluoric acid concentrations to even a small surface area (Wu 2010). Additional treatment measures may be required (eg, magnesium) (Su 2019); consultation with a clinical toxicologist or poison control center is highly recommended.
IV: 2 g immediately or as soon as possible after exposure (before serum calcium level is known). Monitor serum calcium level; if serum calcium level is not within normal range, then give an additional 1 g, followed by 4 g over 1 hour, as needed, to maintain serum calcium levels (Hatzifotis 2004).
Hyperkalemia , severe/emergent (off-label use): Note: Use in patients with hyperkalemia-associated ECG changes or serum potassium >6.5 mEq/L (KDIGO [Clase 2020]). Stabilizes myocardial cell membrane without impacting plasma potassium concentrations; must combine with insulin/dextrose to decrease plasma potassium levels and other therapies to eliminate potassium from body (AHA [Panchal 2020]). Perform continuous cardiac monitoring and obtain serial ECGs (KDIGO [Clase 2020]).
IV, Intraosseous: Initial: 1 to 2 g over 2 to 5 minutes; may repeat after 5 minutes if ECG changes persist or recur, then every 30 to 60 minutes as needed; usual initial dosage range: 1 to 3 g (AHA [Panchal 2020]; Mount 2021).
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.
Radium-226 or strontium-90 internal contamination (off-label use): IV: 2.5 g in 500 mL D5W over 4 to 6 hours once daily for up to 6 days; if possible, administer within 12 hours of radionuclide intake (REMM 2022).
Dosage adjustment for concomitant therapy: Significant drug interactions exist, requiring dose/frequency adjustment or avoidance. Consult drug interactions database for more information.
Initiate with the lower limit of the dosage range (accumulation may occur with renal impairment and subsequent doses may require adjustment based on serum calcium concentrations).
No initial dosage adjustment necessary; subsequent doses should be guided by serum calcium concentrations. In 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).
(For additional information see "Calcium gluconate: Pediatric drug information")
Note : 1 gram calcium gluconate = 93 mg elemental calcium = 4.65 mEq calcium.
Dosages are expressed in terms of the calcium gluconate salt or elemental calcium; use caution.
Calcium channel blocker toxicity, hypotension/conduction disturbances: Infants, Children, and Adolescents: Dose expressed as calcium gluconate: IV: 60 mg/kg/dose administered over 30 to 60 minutes; maximum dose: 3,000 mg/dose (AAP [Shenoi 2020]; Bartlett 2019); some experts recommend rapid administration (eg, infuse over 5 to 10 minutes) and recommend to repeat doses every 10 to 20 minutes up to 3 to 4 doses as needed (Nelson 2019); may also consider IV infusion (Konca 2013). 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 or if administering through a peripheral line (PALS [Kleinman 2010].
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).
Hyperkalemia, adjunctive treatment:
Note: Calcium is administered for myocardium stabilization and prevention of arrhythmias; must be used in conjunction with therapy to shift potassium intracellularly and/or eliminate potassium.
Infants, Children, and Adolescents: Dose expressed as calcium gluconate: IV, Intraosseous: 60 to 100 mg/kg/dose; maximum dose: 2,000 mg/dose; may repeat if necessary (AAP [Shenoi 2020]).
Hypocalcemia, treatment: Dose depends on clinical condition and serum calcium concentration; monitor closely.
Asymptomatic: Limited data available: Infants, Children, and Adolescents: Dose expressed as elemental calcium: Oral: 30 to 75 mg/kg/day in 4 to 5 divided doses (Fuhrman 2017; Sperling 2014). 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).
Mild to moderate symptoms:
IV Intermittent:
Infants, Children, and Adolescents <17 years: Dose expressed as calcium gluconate: IV: 29 to 60 mg/kg/dose every 6 hours (manufacturer's labeling).
Adolescents ≥17 years: Dose expressed as calcium gluconate: IV: 1,000 to 2,000 mg/dose every 6 hours (manufacturer's labeling).
Continuous IV Infusion:
Infants, Children, and Adolescents <17 years: Initial: Dose expressed as calcium gluconate: IV: 8 to 13 mg/kg/hour (manufacturer's labeling).
Adolescents ≥17 years: Initial: Dose expressed as calcium gluconate: IV: 5.4 to 21.5 mg/kg/hour (manufacturer's labeling).
Severe symptoms (eg, seizures, tetany): Infants, Children, and Adolescents: Dose expressed as calcium gluconate: IV, Intraosseous: 100 to 200 mg/kg/dose over 5 to 10 minutes, maximum dose: 1,000 to 2,000 mg/dose; may repeat as needed or follow with a continuous IV infusion of 8 to 32 mg/kg/hour (AAP [Shenoi 2020]; Edmondson 1990; Kelly 2013; Misra 2008; Zhou 2009).
Parenteral nutrition, maintenance calcium requirement (ASPEN [Mirtallo 2004]): Note: Dose expressed as elemental calcium:
Infants and Children ≤50 kg: IV: 0.5 to 4 mEq/kg/day as an additive to parenteral nutrition solution.
Children >50 kg and Adolescents: IV: 10 to 20 mEq/day as an additive to parenteral nutrition solution.
Rickets (due to vitamin D deficiency); treatment: Limited data available: Infants, Children, and Adolescents: 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; Sperling 2014). 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).
Dosage adjustment for concomitant therapy: Significant drug interactions exist, requiring dose/frequency adjustment or avoidance. Consult drug interactions database for more information.
Infants, Children, and Adolescents: Initiate at the lowest dose of the recommended dosage range; monitor serum calcium concentrations closely. Accumulation may occur with renal impairment and subsequent doses may require adjustment based on serum calcium concentrations.
Infants, Children, and Adolescents: No initial dosage adjustment necessary; subsequent doses should be guided by serum calcium concentrations. Hepatic function does not affect the availability of ionized calcium after calcium gluconate administration.
Refer to adult dosing.
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); 1 g in NaCl 0.8% (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]
Yes
1 g calcium gluconate = elemental calcium 93 mg = calcium 4.65 mEq = calcium 2.33 mmol
Excipient information presented when available (limited, particularly for generics); consult specific product labeling.
Solution, Intravenous:
Generic: 10% (10 mL, 50 mL, 100 mL)
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).
Hydrofluoric acid burns, treatment (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.
Oral: Administer with plenty of fluids with or following meals. The 10% calcium gluconate injection may be administered orally in young pediatric patients (Mimouni 1994).
Parenteral: Do not inject calcium salts IM or administer SUBQ since severe necrosis and sloughing may occur; extravasation of calcium can result in severe necrosis and tissue sloughing. Do not use scalp vein or small hand or foot veins for IV administration. Not for endotracheal administration.
Intermittent IV infusion: Vial must be diluted prior to administration; if using premix solution, do not dilute. Infuse dose slowly (not to exceed 100 mg/minute), except in emergency situations; administer through a secure IV line to avoid extravasation, dermal calcium deposits, or tissue necrosis. In acute situations of symptomatic hypocalcemia, infusions over 5 to 10 minutes have been described in pediatric patients (Kelly 2013; Misra 2008).
Continuous IV infusion: Vial must be diluted prior to administration; if using premix solution, do not dilute. Adjust rate as needed based on serum calcium concentrations. Typical rates of administration may vary with indication; refer to institutional protocol.
Parenteral nutrition solution: Calcium-phosphate stability in parenteral nutrition solutions is dependent upon the pH of the solution, temperature, and relative concentration of each ion. The pH of the solution is primarily dependent upon the amino acid concentration. The higher the percentage amino acids the lower the pH, the more soluble the calcium and phosphate. Individual commercially available amino acid solutions vary significantly with respect to pH lowering potential and consequent calcium phosphate compatibility; consult product specific labeling for additional information.
Vesicant; ensure proper needle or catheter placement prior to and during IV infusion. Avoid extravasation.
Early/acute calcium extravasation: If acute extravasation occurs, stop infusion immediately and disconnect (leave needle/cannula in place); gently aspirate extravasated solution (do NOT flush the line); initiate hyaluronidase antidote (See Management of Drug Extravasations for more details); remove needle/cannula; apply dry cold compresses; elevate extremity (Hurst 2004; Reynolds 2014).
Delayed calcium extravasation: If delayed extravasation suspected, closely monitor site; most calcifications spontaneously resolve. However, if a severe manifestation of calcinosis cutis occurs, may initiate sodium thiosulfate antidote (See Management of Drug Extravasations for more details) (Reynolds 2014).
Dietary supplement (oral only): Dietary calcium supplementation
Hypocalcemia (IV only): Treatment of acute symptomatic hypocalcemia in adult and pediatric patients
Beta-blocker overdose; Calcium channel blocker overdose; Hyperkalemia, severe/emergent; Hydrofluoric acid exposure; Radium-226 or strontium-90 internal contamination
Calcium gluconate may be confused with calcium glubionate, cupric sulfate
Calcium gluconate may be confused with calcium chloride.
Confusion with the different intravenous salt forms of calcium has occurred. There is a threefold difference in the primary cation concentration between calcium gluconate (in which 1 g = 4.65 mEq [90 mg] of elemental Ca++) and calcium chloride (in which 1 g = 14 mEq [270 mg] of elemental Ca++).
Prescribers should specify which salt form is desired. Dosages should be expressed either as mEq, mg, or grams of the salt form.
The following adverse drug reactions and incidences are derived from product labeling unless otherwise specified. 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
Hypercalcemia; concomitant use of IV calcium gluconate with ceftriaxone in neonates (≤28 days of age).
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.
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.
None known.
Alpha-Lipoic Acid: Calcium Salts may decrease the absorption of Alpha-Lipoic Acid. Alpha-Lipoic Acid may decrease the absorption of Calcium Salts. Management: Separate administration of alpha-lipoic acid from that of any calcium-containing compounds by several hours. If alpha-lipoic acid is given 30 minutes before breakfast, then administer oral calcium-containing products at lunch or dinner. Risk D: Consider therapy modification
Baloxavir Marboxil: Polyvalent Cation Containing Products may decrease the serum concentration of Baloxavir Marboxil. Risk X: 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. Risk D: 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. Risk D: Consider therapy modification
Cabotegravir: Polyvalent Cation Containing Products may decrease the serum concentration of Cabotegravir. Management: Administer polyvalent cation containing products at least 2 hours before or 4 hours after oral cabotegravir. 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
Cardiac Glycosides: Calcium Salts may enhance the arrhythmogenic effect of Cardiac Glycosides. 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 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. Risk D: 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. Risk D: Consider therapy modification
DOBUTamine: Calcium Salts may diminish the therapeutic effect of DOBUTamine. Risk C: 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. Risk D: 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. Risk D: Consider therapy modification
Elvitegravir: Polyvalent Cation Containing Products may decrease the serum concentration of Elvitegravir. Management: Administer elvitegravir 2 hours before or 6 hours after the administration of polyvalent cation containing products. Risk D: Consider therapy modification
Estramustine: Calcium Salts may decrease the absorption of Estramustine. Management: Administer estramustine on an empty stomach, at least 1 hour before or 2 hours after the dose of an oral calcium supplement. If coadministered with calcium salts, monitor for decreased estramustine therapeutic effects. Risk D: 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. Risk D: Consider therapy modification
Multivitamins/Minerals (with ADEK, Folate, Iron): May increase the serum concentration of Calcium Salts. Risk C: 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. Risk D: 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. Risk D: Consider therapy modification
Quinolones: Calcium Salts may decrease the absorption of Quinolones. Of concern only with oral administration of both agents. Management: Consider administering an oral quinolone at least 2 hours before or 6 hours after the dose of an oral calcium supplement to minimize this interaction. Monitor for decrease therapeutic effects of quinolones during coadministration. Risk D: 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. Risk D: 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. Risk D: Consider therapy modification
Tetracyclines: Calcium Salts may decrease the serum concentration of Tetracyclines. Management: If coadministration of oral calcium with oral tetracyclines cannot be avoided, consider separating administration of each agent by several hours. Risk D: Consider therapy modification
Thiazide and Thiazide-Like 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. Monitor for decreased therapeutic effects of thyroid products if an oral calcium supplement is initiated/dose increased. Risk D: 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. Risk D: Consider therapy modification
Vitamin D Analogs: Calcium Salts may enhance the adverse/toxic effect of Vitamin D Analogs. Risk C: Monitor therapy
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 nonpregnant 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).
Calcium is present in breast milk. The amount of calcium in breast milk is homeostatically regulated and not altered by maternal calcium intake. Calcium requirements are the same in lactating and nonlactating females (IOM 2011). According to the manufacturer, the decision to continue or discontinue breastfeeding during therapy should take into account the risk of infant exposure, the benefits of breastfeeding to the infant, and benefits of treatment to the mother.
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
IV: Serum calcium every 4 to 6 hours (during intermittent infusion), every 1 to 4 hours (during continuous infusion), or every 4 hours in patients with renal impairment; 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).
Serum total calcium: 8.4 to 10.2 mg/dL (2.1 to 2.55 mmol/L). Note: 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.
Serum ionized calcium: 4.48 to 5.32 mg/dL (1.12 to 1.33 mmol/L) (Zaloga 1992)
In low albumin states, the corrected total serum calcium may be estimated by the following equation (assuming a normal albumin of 4 g/dL [40 g/L]).
Corrected total calcium (mg/dL) = measured total calcium (mg/mL) + 0.8 [4-measured serum albumin (g/dL)]
or
Corrected total calcium (mmol/L) = measured total calcium (mmol/L) + 0.02 [40-measured serum albumin (g/L)]
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.
In patients with radium-226 (Ra-226) or strontium-90 internal contamination, calcium gluconate competes for bone binding sites and binds phosphate (REMM 2022).
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%)
Protein binding: ~40%, primarily to albumin
Excretion: Primarily feces (75%; as unabsorbed calcium salts); urine (20%) (IOM 2011)
Solution (Calcium Gluconate Intravenous)
10% (per mL): $0.59
Solution (Calcium Gluconate-NaCl Intravenous)
1GM/100ML 0.8% (per mL): $0.15
1GM/50ML 0.675% (per mL): $0.47
2GM/100ML 0.675% (per mL): $0.47
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