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Sodium bicarbonate: Drug information

Sodium bicarbonate: Drug information
(For additional information see "Sodium bicarbonate: Patient drug information" and see "Sodium bicarbonate: Pediatric drug information")

For abbreviations, symbols, and age group definitions used in Lexicomp (show table)
Brand Names: US
  • Neut
Pharmacologic Category
  • Alkalinizing Agent;
  • Antacid;
  • Electrolyte Supplement, Oral;
  • Electrolyte Supplement, Parenteral
Dosing: Adult

Note: Each oral tablet (650 mg) contains 7.7 mEq each of sodium and bicarbonate. Each mL of 8.4% IV product provides 1 mEq/mL each of sodium and bicarbonate. Avoid extravasation; tissue necrosis may occur due to hypertonicity and alkalinity (Ong 2020).

Antacid: Oral: 325 mg to 2 g 1 to 4 times/day.

Cardiac arrest (ACLS 2010): IV: Initial: 1 mEq/kg/dose; repeat doses should be guided by arterial blood gases.

Routine use of sodium bicarbonate is not recommended. May be considered in the setting of prolonged cardiac arrest only after adequate alveolar ventilation has been established and effective cardiac compressions. Note: In some cardiac arrest situations (eg, metabolic acidosis, hyperkalemia, or tricyclic antidepressant overdose), sodium bicarbonate may be beneficial.

Hyperkalemia , severe/emergent (adjunctive agent) (off-label use): Note: Practice may vary; refer to institutional protocols.

Hyperkalemia with cardiac arrest: Intermittent bolus: IV: 50 mEq over 5 minutes (AHA [Vanden Hoek 2010]).

Hyperkalemia with metabolic acidosis: Note: May consider in patients with persistent severe hyperkalemia and/or ECG changes despite calcium and other therapies to decrease serum potassium, particularly in patients with metabolic acidosis (AHA [Panchal 2020]; Lindner 2020; Mount 2021).

IV: 150 mEq in 1 L of D5W over 2 to 4 hours (Blumberg 1992; Mount 2021).

Metabolic acidosis, acute severe: Note: Must treat underlying cause; the underlying cause and degree of acidosis may result in the need for larger or smaller bicarbonate replacement doses. Consider bicarbonate therapy in patients with either a pH of <7.1 or in patients with severe acute kidney injury and a pH of ≤7.2. In most cases, the initial goal of therapy is to maintain a target pH >7.2 until the primary process causing metabolic acidosis is resolved. In patients with a pH of ≤7.2 and severe acute kidney injury, the initial pH goal is >7.3 (Emmett 2021; Jaber 2018; SCCM [Evans 2021]). Optimal dosing, regimens, administration, and monitoring have not been identified; refer to institutional protocols.

Example regimens:

Intermittent therapy: 7.5% or 8.4% sodium bicarbonate: IV: Initial: 89.2 to 100 mEq once over 1 to 2 minutes; reassess pH, serum bicarbonate level, and clinical status every 2 hours. If pH remains below target (~7.2 to 7.3), administer an additional 44.6 to 100 mEq sodium bicarbonate or initiate a continuous infusion (Emmett 2021).

Example: 100 mEq of 8.4% sodium bicarbonate once over 1 to 2 minutes, then repeat with 50 to 100 mEq or initiate a continuous infusion if pH remains below target (Emmett 2021).

Continuous infusion therapy:

Bicarbonate deficit regimen: Note: Dosing is based on the following bicarbonate deficit formula. This equation provides a very rough estimate of the initial bicarbonate replacement dose; monitor clinical status closely. Some experts prefer intermittent bolus therapy over continuous infusion (Emmett 2021).

Continuous infusion: IV: Sodium bicarbonate estimated dose (mEq) = 0.5 × weight (kg) × [goal serum bicarbonate – observed serum bicarbonate (mEq/L)]; generally, goal serum bicarbonate is ~8 to 12 mEq/L (Adrogué 1998; Kraut 2012; Sabatini 2009). Note: In the equation above, "0.5 × weight (kg)" represents the estimated bicarbonate Vd.

Note: Administer the calculated amount of bicarbonate (mEq) over several hours (eg, 2 to 4 hours) until pH is ~7.2 to 7.3; reassess pH, serum bicarbonate level, and clinical status every 2 hours, and adjust dose as needed until goals are reached (Emmett 2021; Kraut 2012).

Example: For estimated bicarbonate deficit of 150 mEq, administer sodium bicarbonate [8.4%] 150 mEq in 1 L D5W over 2 to 4 hours, then reassess pH, serum bicarbonate level, and clinical status. Adjust dose if pH remains below target (Emmett 2021; Kraut 2012).

Metabolic acidosis in patients with chronic kidney disease: Oral (off-label): Note: KDIGO guidelines suggest oral replacement when plasma HCO3- concentrations are <22 mEq/L (KDIGO 2013).

Initial: 15.4 to 23.1 mEq/day in divided doses (eg, 650 mg tablet 2 to 3 times daily); titrate to normal serum bicarbonate concentrations (eg, 23 to 29 mEq/L, although a more targeted range of 24 to 26 mEq/L has been suggested by observational studies [Dobre 2015; Raphael 2019]) or up to 5,850 mg/day; baking soda may be used as an alternative in patients who cannot take tablets (Chen 2014; KDIGO 2013; Kovesdy 2009; Raphael 2016). Avoid exceeding serum bicarbonate concentrations >29 mEq/L since this has been associated with increased mortality in patients with chronic kidney disease (Kovesdy 2009; Raphael 2019).

Neutralize lidocaine with epinephrine dental anesthetic: Neutralizing additive: Mix 10 parts anesthetic (lidocaine with epinephrine) to 1 part 8.4% sodium bicarbonate.

Add 0.18 mL sodium bicarbonate to 1.8 mL cartridge of lidocaine 2% with epinephrine 1:50,000 or 1:100,000.

Add 2 mL sodium bicarbonate to 20 mL vial of lidocaine 2% with epinephrine 1:100,000.

Add 3 mL sodium bicarbonate to 30 mL vial of lidocaine 2% with epinephrine 1:100,000.

Add 5 mL sodium bicarbonate to 50 mL vial of lidocaine 2% with epinephrine 1:100,000.

Prevention of contrast-induced nephropathy (off-label use): IV infusion: 154 mEq/L sodium bicarbonate in D5W solution: 3 mL/kg/hour for 1 hour immediately before contrast injection, then 1mL/kg/hour during contrast exposure and for 6 hours after procedure (Merten 2004). Some have described a prophylactic strategy based on patient risk for contrast induced nephropathy and procedure type (Goldfarb 2009). Note: In patients at high risk for renal complications, no benefit was seen with IV sodium bicarbonate over IV sodium chloride in one study; therefore, some consider IV sodium chloride as the preferred option due to lower cost and no need for compounding (Rosner 2018; Weisbord 2018).

Renal tubular acidosis: Oral:

Distal: 0.5 to 2 mEq/kg/day in 4 to 5 divided doses.

Proximal: Initial: 5 to 10 mEq/kg/day; maintenance: Increase as required to maintain serum bicarbonate in the normal range.

Urine alkalinization: Oral: Initial: 48 mEq (4 g), then 12 to 24 mEq (1 to 2 g) every 4 hours; dose should be titrated to desired urinary pH; doses up to 16 g/day (200 mEq) in patients <60 years and 8 g (100 mEq) in patients >60 years. Administration of 48 mEq (4 g) every 8 hours for a total daily dose of 144 mEq (12 g) has also been shown to achieve a urinary pH of at least 7 after a period of 10 hours in one study of healthy volunteers (Cohen 2013). Note: Intravenous administration is preferred in specific overdoses (eg, salicylate) with a target urinary pH of 7.5 to 8.5 (Levine 2011; Proudfoot 2004).

Dosing: Kidney Impairment: Adult

The renal dosing recommendations are based upon the best available evidence and clinical expertise. Senior Editorial Team: Bruce Mueller, PharmD, FCCP, FASN, FNKF; Jason Roberts, PhD, BPharm (Hons), B App Sc, FSHP, FISAC; Michael Heung, MD, MS.

Note: Contains sodium; use with caution, especially in patients with concomitant hypertension, heart failure, or volume overload (Chen 2014).

Altered kidney function: No dosage adjustment necessary for any degree of kidney dysfunction (expert opinion).

Hemodialysis, intermittent (thrice weekly): No dosage adjustment necessary (expert opinion).

Peritoneal dialysis: No dosage adjustment necessary (expert opinion).

CRRT: No dosage adjustment necessary (expert opinion).

PIRRT (eg, sustained, low-efficiency diafiltration): No dosage adjustment necessary (expert opinion).

Dosing: Hepatic Impairment: Adult

There are no dosage adjustments provided in the manufacturer's labeling. Use with caution, especially in clinical states associated with edema and sodium retention.

Dosing: Pediatric

(For additional information see "Sodium bicarbonate: Pediatric drug information")

Note: Dose should be individualized to patient response and target parameters for condition being treated.

Antacid: Note: Chronic antacid therapy not recommended for management of GERD in pediatric patients (AAP [Lightdale 2013]; NASPGHAN/ESPGHAN [Vandenplas 2009]). Children ≥5 years and Adolescents: Oral powder: Oral: 1/2 teaspoonful/dose; may repeat up to every 2 hours not to exceed 7 doses in 24 hours, and do not use longer than 2 weeks.

Cardiac arrest (PALS guidelines): Infants, Children, and Adolescents: IV, Intraosseous: 1 mEq/kg/dose; repeat doses should be guided by arterial blood gases; in infants and children <2 years of age, the 4.2% (0.5 mEq/mL) solution may be preferred per the manufacturer's labeling. Note: If intraosseous route is used for administration and is subsequently used to obtain blood samples for acid-base analysis, results will be inaccurate (AHA [Kleinman 2010).

Note: Routine use of sodium bicarbonate (NaHCO3) is not recommended. May be considered in the setting of prolonged cardiac arrest only after adequate alveolar ventilation has been established and effective cardiac compressions. Note: In some cardiac arrest situations (eg, metabolic acidosis, hyperkalemia, or tricyclic antidepressant overdose), sodium bicarbonate may be beneficial (AHA [Kleinman 2010).

Chronic kidney disease (CKD) acidosis: Limited data available: Note: Initiate if serum bicarbonate <22 mEq/L (KDIGO 2012): Infants, Children, and Adolescents: Oral: Initial dose based on serum bicarbonate levels (see following equation); may divide dose for tolerability (Kraut 2011); adjust dose to maintain serum bicarbonate within the targeted normal range (eg, children: 22 to 23 mEq/L; adults: 24 to 25 mEq/L); undertreatment should be avoided due to negative effects of acidosis on growth (KDIGO 2012).

HCO3-(mEq) = 0.5 x weight (kg) x [desired HCO3- (mEq/L) - serum HCO3-(mEq/L)]

Hyperkalemia; adjunct: Limited data available; efficacy results variable: Infants, Children, and Adolescents: IV: 1 to 2 mEq/kg/dose has been used to redistribute extracellular potassium into cells based on physiologic understanding (Hegenbarth 2008); however, some data has shown efficacy lacking for use in acute, early treatment of hyperkalemia (ie, 60 minutes); in adult dialysis patients, while short infusions were shown to increase serum bicarbonate, they were not shown to reduce serum potassium (Ahee 2000; Blumberg 1988; Gutierrez 1991; Kim 1996; Weisberg 2008); some efficacy was observed with a long duration hypertonic bicarbonate infusion (eg, 150 mEq/L in D5W) used as rehydration fluid and/or in presence of metabolic acidosis (Weiner 1998; Weisberg 2008); serum Na should also be monitored closely.

Metabolic acidosis, acute: Infants, Children, and Adolescents:

Blood-gas directed dosing (equations): IV: These equations provide an estimated replacement dose. The underlying cause and degree of acidosis may result in the need for larger or smaller replacement doses. In most cases, the initial goal of therapy is to target a pH of ~7.2 to prevent overalkalinization (Adrogué 2006; Fuhrman 2011).

HCO3-(mEq) = 0.3 x weight (kg) x base deficit (mEq/L) or

HCO3-(mEq) = 0.5 x weight (kg) x [24 - serum HCO3-(mEq/L)]

Administer 1/2 calculated dose initially, then remaining 1/2 dose over the next 24 hours; monitor pH, serum HCO3-, and clinical status.

Weight-directed dosing (if acid-base status is not available): Infants, Children, and Adolescents: IV, Intraosseous: 1 to 2 mEq/kg/dose (Hegenbarth 2008), in older Children (>2 years) and Adolescents: 2 to 5 mEq/kg IV infusion over 4 to 8 hours; subsequent doses should be based on patient's acid-base status.

Neutralization local (dental) anesthetic (lidocaine with epinephrine): Neutralizing additive: Mix 10 parts anesthetic (lidocaine with epinephrine) to 1 part 8.4% sodium bicarbonate.

Add 0.18 mL sodium bicarbonate to 1.8 mL cartridge of lidocaine 2% with epinephrine 1:50,000 or 1:100,000.

Add 2 mL sodium bicarbonate to 20 mL vial of lidocaine 2% with epinephrine 1:100,000.

Add 3 mL sodium bicarbonate to 30 mL vial of lidocaine 2% with epinephrine 1:100,000.

Add 5 mL sodium bicarbonate to 50 mL vial of lidocaine 2% with epinephrine 1:100,000.

Renal tubular acidosis (RTA): Limited data available: Note: Dose should be individualized based on urinary bicarbonate excretion (degree depends on type of RTA), serum bicarbonate, and possibly age-related factors; undertreatment should be avoided due to negative effects of acidosis on growth (KDIGO 2012).

Distal; type 1: Dose requirements may vary with age; some data suggests infants and children <6 years require higher daily dose than older children (Rodriguez-Soriano 1982); daily dose should replace urinary excretion and endogenous production (McSherry 1972, Rodriguez-Soriano 1982).

Infants: Oral: Usual range: 5 to 8 mEq/kg/day (Rodriguez-Soriano 2002); reported range: 3.9 to 10 mEq/kg/day (Rodriguez-Soriano 1982).

Children and Adolescents: Oral: Initial: At least 3 mEq/kg/day; usual initial range: 3 to 4 mEq/kg/day; titrate as necessary (Rodriguez-Soriano 1982, Rodriguez-Soriano 2002, Santos 1986).

Proximal, type 2: Infants, Children, and Adolescents: Oral: Initial: 5 to 10 mEq/kg/day in divided doses; usual range: 10 to 20 mEq/kg/day; titrate as necessary to target serum bicarbonate (Chan 2001; Rodriguez-Soriano 2002).

Skin protectant; relief of minor irritation: Note: Notify physician if no symptom resolution within 7 days, or if symptoms reappear after an initial resolution. Children ≥2 years and Adolescents: Topical: Oral powder (baking soda):

Bath soak: Dissolve 1 to 2 cups in tub of warm water, soak for 10 to 30 minutes; pat skin dry.

Compress or wet dressing: Mix powder with water; soak clean soft cloth with mixture, apply cloth loosely to affected area for 15 to 30 minutes; may repeat as needed or as directed by physician.

Paste: Mix powder with water to form a paste, apply to the affected area of skin as needed.

Tricyclic antidepressant (TCA, Na channel blocker), overdose: Limited data available: Infants, Children, and Adolescents: IV, Intraosseous: 1 to 2 mEq/kg/dose; titrate to maintain serum pH 7.45 to 7.55, follow with 150 mEq NaHCO3/L infusion to maintain targeted pH (Hegenbarth 2008).

Dosing: Kidney Impairment: Pediatric

There are no dosage adjustments provided in the manufacturer's labeling. Use with caution; can cause sodium retention.

Dosing: Hepatic Impairment: Pediatric

There are no dosage adjustments provided in the manufacturer's labeling. Use with caution, especially in clinical states associated with edema and sodium retention.

Dosing: Older Adult

Refer to adult dosing.

Dosage Forms: US

Excipient information presented when available (limited, particularly for generics); consult specific product labeling.

Powder, Oral:

Generic: (1 g, 120 g, 454 g, 500 g, 1000 g, 2500 g, 10000 g, 12000 g, 25000 g, 45000 g)

Solution, Intravenous:

Neut: 4% (5 mL)

Generic: 4.2% (5 mL, 10 mL); 8.4% (10 mL, 50 mL)

Solution, Intravenous [preservative free]:

Generic: 4.2% (5 mL); 7.5% (50 mL); 8.4% (50 mL)

Tablet, Oral:

Generic: 325 mg, 650 mg

Generic Equivalent Available: US

Yes

Dosage Forms Considerations

Sodium bicarbonate solution 4.2% [42 mg/mL] provides 0.5 mEq/mL each of sodium and bicarbonate

Sodium bicarbonate solution 7.5% [75 mg/mL] provides 0.9 mEq/mL each of sodium and bicarbonate

Sodium bicarbonate solution 8.4% [84 mg/mL] provides 1 mEq/mL each of sodium and bicarbonate

Dosage Forms: Canada

Excipient information presented when available (limited, particularly for generics); consult specific product labeling.

Solution, Intravenous:

Generic: 4.2% (10 mL); 7.5% (50 mL); 8.4% (10 mL, 50 mL)

Administration: Adult

IV: For direct IV infusion in emergencies, administer slowly; for infusion, dilute to a maximum concentration of 0.5 mEq/mL in dextrose solution and infuse over at least 2 hours (maximum rate of administration: 1 mEq/kg/hour).

Vesicant (at concentrations ≥8.4%); 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); initiate hyaluronidase antidote; remove needle/cannula; apply dry cold compresses (Hurst 2004; Reynolds 2014); elevate extremity.

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 (Reynolds 2014).

Oral product should be administered 1 to 3 hours after meals.

Infiltration (dental use; Onpharma): Add specified volume of 8.4% sodium bicarbonate directly with lidocaine and epinephrine injection and mix; use immediately after mixing.

Administration: Pediatric

Oral: Administer 1 to 3 hours after meals

Powder (including baking soda): Measure dose exactly, mix with adequate amount of water (eg, 1/2 teaspoon baking soda with 4 ounces of water), allow to dissolve completely prior to administration

Parenteral:

Direct IV injection:

Neonates and Infants: Administer 0.5 mEq/mL solution (either using the 0.5 mEq/mL solution undiluted or dilute the 1 mEq/mL solution 1:1 with SWFI); administer slowly, maximum rate: 10 mEq/minute

Children and Adolescents: Administer 1 mEq/mL solution; administer slowly

IV infusion: Must be diluted prior to administration; infusion time variable based upon use; for metabolic acidosis, infusions over 2 to 8 hours have been suggested; maximum rate of administration: 1 mEq/kg/hour

Vesicant (at concentrations ≥8.4%); ensure proper needle or catheter placement prior to and during IV infusion. Avoid extravasation. If 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 (Hurst 2004; Reynolds 2014); elevate extremity.

Topical: Paste, compress/dressing: Apply to clean affected area

Use: Labeled Indications

Management of metabolic acidosis; gastric hyperacidity; alkalinization of the urine; management of overdose of certain drugs, including tricyclic antidepressants and aspirin.

Neutralizing additive (IV use): To reduce the incidence of chemical phlebitis and patient discomfort due to vein irritation at or near the infusion site by raising the pH of IV acid solutions.

Neutralizing additive (dental use): Improves onset of analgesia and reduces injection site pain by adjusting lidocaine with epinephrine solution to a more physiologic pH.

Use: Off-Label: Adult

Contrast-induced nephropathy (prevention); Hyperkalemia, severe/emergent

Adverse Reactions

The following adverse drug reactions and incidences are derived from product labeling unless otherwise specified.

Frequency not defined.

Cardiovascular: Cardiac failure (exacerbation), edema

Central nervous system: Cerebral hemorrhage

Endocrine & metabolic: Acidosis (intracranial), hypernatremia, hypocalcemia, hypokalemia, metabolic alkalosis, milk-alkali syndrome (especially with renal dysfunction)

Gastrointestinal: Abdominal distention, eructation, flatulence (oral administration)

Neuromuscular & skeletal: Tetany

Respiratory: Pulmonary edema

Contraindications

Chloride loss due to vomiting or from continuous GI suction; concomitant use of diuretics known to produce a hypochloremic alkalosis.

Neutralizing additive (dental or IV use): Not for use as a systemic alkalizer.

Warnings/Precautions

Concerns related to adverse effects:

• Extravasation: Vesicant (at concentrations ≥8.4%); ensure proper catheter or needle position prior to and during infusion. Avoid extravasation (tissue necrosis may occur due to hypertonicity and alkalinity) (Ong 2020).

Disease-related concerns:

• Cirrhosis: Use with caution in patients with cirrhosis.

• Edema: Use with caution in patients with edema.

• Heart failure: Use with caution in patients with heart failure.

• Peptic ulcer disease: Not to be used in treatment of peptic ulcer disease.

• Renal impairment: Use with caution in patients with renal impairment; may cause sodium retention.

Special populations:

• Elderly: Not the antacid of choice for the elderly because of sodium content and potential for systemic alkalosis.

• Pediatric: Rapid administration in neonates, infants, and children <2 years of age has led to hypernatremia, decreased CSF pressure, and intracranial hemorrhage.

Dosage form specific issues:

• Injection: Use of IV sodium bicarbonate should be reserved for documented severe metabolic acidosis and for severe/emergent hyperkalemia (eg, cardiotoxicity or cardiac arrest). Routine use in cardiac arrest is not recommended.

Metabolism/Transport Effects

None known.

Drug Interactions

Acalabrutinib: Antacids may decrease the serum concentration of Acalabrutinib. Management: Separate administration of acalabrutinib from the administration of any antacids by at least 2 hours in order to minimize the potential for a significant interaction. Risk D: Consider therapy modification

AcetaZOLAMIDE: May enhance the adverse/toxic effect of Sodium Bicarbonate. Specifically, the risk of renal calculus formation may be increased. Risk C: Monitor therapy

Alpha-/Beta-Agonists (Indirect-Acting): Alkalinizing Agents may increase the serum concentration of Alpha-/Beta-Agonists (Indirect-Acting). Risk C: Monitor therapy

Amantadine: Alkalinizing Agents may increase the serum concentration of Amantadine. Risk C: Monitor therapy

Amphetamines: Alkalinizing Agents may decrease the excretion of Amphetamines. Management: Consider alternatives to using amphetamines and alkalinizing agents in combination. If these agents must be used together, patients should be monitored closely for excessive amphetamine effects. Risk D: Consider therapy modification

Antipsychotic Agents (Phenothiazines): Antacids may decrease the absorption of Antipsychotic Agents (Phenothiazines). Risk C: Monitor therapy

Atazanavir: Antacids may decrease the absorption of Atazanavir. Management: Administer antacids 1 to 2 hours before or 2 hours after atazanavir to minimize the risk of a clinically significant interaction. Risk D: Consider therapy modification

Belumosudil: Antacids may decrease the serum concentration of Belumosudil. Management: Consider separating administration of belumosudil and antacids by 2 hours and monitor for reduced belumosudil efficacy. Risk D: Consider therapy modification

Bisacodyl: Antacids may diminish the therapeutic effect of Bisacodyl. Antacids may cause the delayed-release bisacodyl tablets to release drug prior to reaching the large intestine. Gastric irritation and/or cramps may occur. Management: Antacids should not be used within 1 hour before bisacodyl administration. Risk D: Consider therapy modification

Bismuth Subcitrate: Antacids may diminish the therapeutic effect of Bismuth Subcitrate. Management: Avoid administration of antacids within 30 minutes of bismuth subcitrate (tripotassium bismuth dicitrate) administration. Risk D: Consider therapy modification

Bosutinib: Antacids may decrease the serum concentration of Bosutinib. Management: Administer antacids more than 2 hours before or after bosutinib. Risk D: Consider therapy modification

Bromperidol: Antacids may decrease the absorption of Bromperidol. Risk C: Monitor therapy

Calcium Polystyrene Sulfonate: Antacids may enhance the adverse/toxic effect of Calcium Polystyrene Sulfonate. The combined use of these two agents may result in metabolic alkalosis and/or loss of efficacy of the cation exchange resin. Management: To minimize this interaction, consider: a)separating doses by 2 or more hours; b)rectal administration of the exchange resin; or c)alternatives to antacids. Monitor for metabolic alkalosis and attenuation of CPS effects. Avoid magnesium hydroxide. Risk D: Consider therapy modification

Captopril: Antacids may decrease the serum concentration of Captopril. Risk C: Monitor therapy

Cefditoren: Antacids may decrease the serum concentration of Cefditoren. Management: Concomitant use of cefditoren with antacids is not recommended. Consider alternative methods to control acid reflux (eg, diet modification) or alternative antimicrobial therapy. If antacid therapy can not be avoided, separate dosing by several hours. Risk D: Consider therapy modification

Cefpodoxime: Antacids may decrease the serum concentration of Cefpodoxime. Risk C: Monitor therapy

Cefuroxime: Antacids may decrease the serum concentration of Cefuroxime. Management: Administer cefuroxime axetil at least 1 hour before or 2 hours after the administration of short-acting antacids. Risk D: Consider therapy modification

Chloroquine: Antacids may decrease the serum concentration of Chloroquine. Management: Separate the administration of antacids and chloroquine by at least 4 hours to minimize any potential negative impact of antacids on chloroquine bioavailability. Risk D: Consider therapy modification

Corticosteroids (Oral): Antacids may decrease the bioavailability of Corticosteroids (Oral). Management: Consider separating doses by 2 or more hours. Budesonide enteric coated tablets could dissolve prematurely if given with drugs that lower gastric acid, with unknown impact on budesonide therapeutic effects. Risk D: Consider therapy modification

Cysteamine (Systemic): Antacids may diminish the therapeutic effect of Cysteamine (Systemic). Risk C: Monitor therapy

Dabigatran Etexilate: Antacids may decrease the serum concentration of Dabigatran Etexilate. Management: Dabigatran etexilate Canadian product labeling recommends avoiding concomitant use with antacids for 24 hours after surgery. In other situations, administer dabigatran etexilate 2 hours prior to antacids. Monitor clinical response to dabigatran therapy. Risk D: Consider therapy modification

Dasatinib: Antacids may decrease the serum concentration of Dasatinib. Management: Simultaneous administration of dasatinib and antacids should be avoided. Administer antacids 2 hours before or 2 hours after dasatinib. Risk D: Consider therapy modification

Delavirdine: Antacids may decrease the serum concentration of Delavirdine. Management: Separate doses of delavirdine and antacids by at least 1 hour. Monitor for decreased delavirdine therapeutic effects with this combination. Risk D: Consider therapy modification

Erlotinib: Antacids may decrease the serum concentration of Erlotinib. Management: Separate the administration of erlotinib and any antacid by several hours in order to minimize the risk of a significant interaction. Risk D: Consider therapy modification

Flecainide: Sodium Bicarbonate may increase the excretion of Flecainide. Sodium Bicarbonate may increase the serum concentration of Flecainide. Risk C: Monitor therapy

Fosinopril: Antacids may decrease the serum concentration of Fosinopril. Management: The US and Canadian fosinopril manufacturer labels recommend separating the doses of antacids and fosinopril by 2 hours. Risk D: Consider therapy modification

Gefitinib: Antacids may decrease the serum concentration of Gefitinib. Management: Administer gefitinib at least 6 hours before or 6 hours after administration of an antacid, and closely monitor clinical response to gefitinib. Risk D: Consider therapy modification

Hyoscyamine: Antacids may decrease the serum concentration of Hyoscyamine. Management: Administer immediate release hyoscyamine before meals and antacids after meals when these agents are given in combination. Risk D: Consider therapy modification

Infigratinib: Antacids may decrease serum concentrations of the active metabolite(s) of Infigratinib. Antacids may decrease the serum concentration of Infigratinib. Management: Avoid coadministration of infigratinib with antacids or other gastric acid-lowering agents. If antacids cannot be avoided, administer infigratinib 2 hours before or after administration of antacids. Risk D: Consider therapy modification

Iron Preparations: Antacids may decrease the absorption of Iron Preparations. Management: No action is likely necessary for the majority of patients who only use antacids intermittently or occasionally. Consider separating doses of oral iron and antacids in patients who require chronic use of both agents and monitor for reduced iron efficacy. Risk D: Consider therapy modification

Isoniazid: Antacids may decrease the absorption of Isoniazid. Risk C: Monitor therapy

Itraconazole: Antacids may decrease the serum concentration of Itraconazole. Antacids may increase the serum concentration of Itraconazole. Management: Administer Sporanox brand itraconazole at least 2 hours before or 2 hours after administration of any antacids. Exposure to Tolsura brand itraconazole may be increased by antacids; consider itraconazole dose reduction. Risk D: Consider therapy modification

Ketoconazole (Systemic): Antacids may decrease the serum concentration of Ketoconazole (Systemic). Management: Administer oral ketoconazole at least 2 hours prior to use of any antacid product. Monitor patients closely for signs of inadequate clinical response to ketoconazole. Risk D: Consider therapy modification

Lanthanum: Antacids may diminish the therapeutic effect of Lanthanum. Management: Administer antacid products at least 2 hours before or after lanthanum. Risk D: Consider therapy modification

Ledipasvir: Antacids may decrease the serum concentration of Ledipasvir. Management: Separate the administration of ledipasvir and antacids by 4 hours. Risk D: Consider therapy modification

Levoketoconazole: Antacids may decrease the absorption of Levoketoconazole. Management: Advise patients to take antacids at least 2 hours after taking levoketoconazole. Risk D: Consider therapy modification

Lithium: Sodium Bicarbonate may increase the excretion of Lithium. Risk C: Monitor therapy

Mecamylamine: Alkalinizing Agents may increase the serum concentration of Mecamylamine. Risk C: Monitor therapy

Memantine: Alkalinizing Agents may increase the serum concentration of Memantine. Risk C: Monitor therapy

Mesalamine: Antacids may diminish the therapeutic effect of Mesalamine. Antacid-mediated increases in gastrointestinal pH may cause the premature release of mesalamine from specific sustained-release mesalamine products. Management: Avoid concurrent administration of antacids with the Apriso brand of mesalamine extended-release capsules. The optimal duration of dose separation is unknown. Other mesalamine products do not contain this interaction warning. Risk D: Consider therapy modification

Methenamine: Antacids may diminish the therapeutic effect of Methenamine. Management: Consider avoiding this combination if possible. Antacids may decrease the therapeutic effects of methenamine; sodium bicarbonate is of most concern. If coadministering methenamine and antacids, monitor for decreased methenamine efficacy. Risk D: Consider therapy modification

Multivitamins/Minerals (with ADEK, Folate, Iron): Antacids may decrease the serum concentration of Multivitamins/Minerals (with ADEK, Folate, Iron). Specifically, antacids may decrease the absorption of orally administered iron. Management: Separate dosing of oral iron-containing multivitamins and antacids by as much time as possible to minimize impact of this interaction. Monitor for decreased therapeutic efficacy of oral iron preparations during coadministration. Risk D: Consider therapy modification

Naproxen: Antacids may decrease the absorption of Naproxen. Risk X: Avoid combination

Neratinib: Antacids may decrease the serum concentration of Neratinib. Specifically, antacids may reduce neratinib absorption. Management: Separate the administration of neratinib and antacids by giving neratinib at least 3 hours after the antacid. Risk D: Consider therapy modification

Nilotinib: Antacids may decrease the serum concentration of Nilotinib. Management: Separate the administration of nilotinib and any antacid by at least 2 hours whenever possible in order to minimize the risk of a significant interaction. Risk D: Consider therapy modification

Octreotide: Antacids may decrease the serum concentration of Octreotide. Risk C: Monitor therapy

PAZOPanib: Antacids may decrease the serum concentration of PAZOPanib. Management: Avoid the use of antacids in combination with pazopanib whenever possible. Separate doses by several hours if antacid treatment is considered necessary. The impact of dose separation has not been investigated. Risk D: Consider therapy modification

Pexidartinib: Antacids may decrease the serum concentration of Pexidartinib. Management: Administer pexidartinib 2 hours before or after antacids. Risk D: Consider therapy modification

Phosphate Supplements: Antacids may decrease the absorption of Phosphate Supplements. Management: This applies only to oral phosphate administration. Separating administration of oral phosphate supplements from antacid administration by as long as possible may minimize the interaction. Risk D: Consider therapy modification

Potassium Phosphate: Antacids may decrease the serum concentration of Potassium Phosphate. Management: Consider separating administration of antacids and oral potassium phosphate by at least 2 hours to decrease risk of a significant interaction. Risk D: Consider therapy modification

QuiNIDine: Antacids may decrease the excretion of QuiNIDine. Risk C: Monitor therapy

QuiNINE: Alkalinizing Agents may increase the serum concentration of QuiNINE. Risk C: Monitor therapy

Rilpivirine: Antacids may decrease the serum concentration of Rilpivirine. Management: Administer antacids at least 2 hours before or 4 hours after rilpivirine when used with most rilpivirine products. However, administer antacids at least 6 hours before or 4 hours after the rilpivirine/dolutegravir combination product. Risk D: Consider therapy modification

Riociguat: Antacids may decrease the serum concentration of Riociguat. Management: Separate the administration of antacids and riociguat by at least 1 hour in order to minimize any potential interaction. Monitor clinical response to riociguat more closely in patients using this combination. Risk D: Consider therapy modification

Rosuvastatin: Antacids may decrease the serum concentration of Rosuvastatin. Risk C: Monitor therapy

Selpercatinib: Antacids may decrease the serum concentration of Selpercatinib. Management: Coadministration of selpercatinib and antacids should be avoided. If coadministration cannot be avoided, selpercatinib should be administered 2 hours before or 2 hours after antacids. Risk D: Consider therapy modification

Sodium Polystyrene Sulfonate: Antacids may enhance the adverse/toxic effect of Sodium Polystyrene Sulfonate. Specifically, the risk of metabolic alkalosis may be increased. Antacids may diminish the therapeutic effect of Sodium Polystyrene Sulfonate. Risk C: Monitor therapy

Sotalol: Antacids may decrease the serum concentration of Sotalol. Management: Avoid simultaneous administration of sotalol and antacids. Administer antacids 2 hours after sotalol. Risk D: Consider therapy modification

Sotorasib: Antacids may decrease the serum concentration of Sotorasib. Management: Avoid coadministration of sotorasib and antacids. If use of a gastric acid suppressing medication cannot be avoided, administer sotorasib 4 hours before or 10 hours after oral antacid administration. Risk D: Consider therapy modification

Sulpiride: Antacids may decrease the serum concentration of Sulpiride. Management: Separate administration of antacids and sulpiride by at least 2 hours in order to minimize the impact of antacids on sulpiride absorption. Risk D: Consider therapy modification

Tetracyclines: Antacids may decrease the absorption of Tetracyclines. Management: Separate administration of antacids and oral tetracycline derivatives by several hours when possible to minimize the extent of this potential interaction. Monitor for decreased therapeutic effects of tetracyclines. Risk D: Consider therapy modification

Velpatasvir: Antacids may decrease the serum concentration of Velpatasvir. Management: Separate administration of velpatasvir and antacids by at least 4 hours. Risk D: Consider therapy modification

Pregnancy Considerations

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 (Campbell 2009; Jeejeebhoy [AHA] 2015). Antacids containing sodium bicarbonate should not be used during pregnancy due to their potential to cause metabolic alkalosis and fluid overload in the mother and fetus (Body 2016; Dağlı 2017; Gomes 2018; Thélin 2020).

Breastfeeding Considerations

Sodium is found in breast milk (IOM 2004).

Dietary Considerations

Some products may contain sodium. Oral product should be taken 1 to 3 hours after meals.

Monitoring Parameters

Serum electrolytes (including bicarbonate, potassium, calcium), urinary pH, arterial blood gases (if indicated).

Mechanism of Action

Dissociates to provide bicarbonate ion which neutralizes hydrogen ion concentration and raises blood and urinary pH

Neutralizing additive (dental use): Increases pH of lidocaine and epinephrine solution to improve tolerability and increase tissue uptake

Pharmacokinetics

Onset of action: Oral: 15 minutes; IV: Rapid

Duration: Oral: 1 to 3 hours; IV: 8 to 10 minutes

Absorption: Oral: Well absorbed

Excretion: Urine (<1%)

Pricing: US

Solution (Sodium Bicarbonate Intravenous)

4.2% (per mL): $1.86 - $4.95

7.5% (per mL): $0.39

8.4% (per mL): $0.15 - $0.52

Tablets (Sodium Bicarbonate Oral)

325 mg (per each): $0.01 - $0.05

650 mg (per each): $0.01 - $0.05

Disclaimer: A representative AWP (Average Wholesale Price) price or price range is provided as reference price only. A range is provided when more than one manufacturer's AWP price is available and uses the low and high price reported by the manufacturers to determine the range. The pricing data should be used for benchmarking purposes only, and as such should not be used alone to set or adjudicate any prices for reimbursement or purchasing functions or considered to be an exact price for a single product and/or manufacturer. Medi-Span expressly disclaims all warranties of any kind or nature, whether express or implied, and assumes no liability with respect to accuracy of price or price range data published in its solutions. In no event shall Medi-Span be liable for special, indirect, incidental, or consequential damages arising from use of price or price range data. Pricing data is updated monthly.

Brand Names: International
  • Betsol "Z" (MX);
  • Bicart (EG);
  • Natribic (BE);
  • Natrium bicarbonicum (PL);
  • Solunate (PH)


For country abbreviations used in Lexicomp (show table)

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