Medication Guide App

Calcium Supplements (Systemic)

This monograph includes information on the following:

1) Calcium Acetate 
2) Calcium Carbonate
3) Calcium Chloride
4) Calcium Citrate 
5) Calcium Glubionate§
6) Calcium Gluceptate  
7) Calcium Gluceptate and Calcium Gluconate *
8) Calcium Gluconate
9) Calcium Glycerophosphate and Calcium Lactate 
10) Calcium Lactate
11) Calcium Lactate-Gluconate and Calcium Carbonate *
12) Dibasic Calcium Phosphate  
13) Tribasic Calcium Phosphate  


INN:
Calcium Gluceptate—Calcium Glucoheptonate

VA CLASSIFICATION
Calcium Acetate Parenteral
Primary: TN402

Calcium Carbonate Oral
Primary: TN402
Secondary: GA105

Calcium Chloride Parenteral
Primary: TN402
Secondary: CV900

Calcium Citrate Oral
Primary: TN402

Calcium Glubionate Oral
Primary: TN402

Calcium Gluceptate Parenteral
Primary: TN402

Calcium Gluceptate and Calcium Gluconate Oral
Primary: TN402

Calcium Gluconate Oral
Primary: TN402

Calcium Gluconate Parenteral
Primary: TN402
Secondary: CV900

Calcium Glycerophosphate and Calcium Lactate Parenteral
Primary: TN402

Calcium Lactate Oral
Primary: TN402

Calcium Lactate-Gluconate and Calcium Carbonate Oral
Primary: TN402

Dibasic Calcium Phosphate Oral
Primary: TN402

Tribasic Calcium Phosphate Oral
Primary: TN402


Commonly used brand name(s): Alka-Mints2; Amitone2; Apo-Cal2; BioCal2; Cal-Plus2; Calcarb 6002; Calci-Chew2; Calci-Mix2; Calciday 6672; Calciject3; Calcilac2; Calcionate5; Calcite 5002; Calcium 6002; Calcium Stanley7; Calcium-Sandoz5; Calcium-Sandoz Forte11; Calglycine2; Calphosan9; Calsan2; Caltrate 6002; Caltrate Jr2; Chooz2; Citracal4; Citracal Liquitabs4; Dicarbosil2; Gencalc 6002; Gramcal11; Liqui-Cal2; Liquid Cal-6002; Maalox Antacid Caplets2; Mallamint2; Neo-Calglucon5; Nephro-Calci2; Nu-Cal2; Os-Cal2; Os-Cal 5002; Os-Cal Chewable2; OsCal 500 Chewable2; Oysco2; Oysco 500 Chewable2; Oyst-Cal 5002; Oystercal 5002; Posture13; Rolaids Calcium Rich2; Titralac2; Tums2; Tums 5002; Tums E-X2; Tums Extra Strength2; Tums Regular Strength2.

 Antacid product commonly recommended as calcium supplement.
§ In Canada, calcium glubionate is known as calcium glucono-galacto gluconate.
Note: For a listing of dosage forms and brand names by country availability, see Dosage Forms section(s).

*Not commercially available in the U.S.

Not commercially available in Canada.



Category:


Antihypocalcemic—Calcium Acetate; Calcium Carbonate; Calcium Chloride; Calcium Citrate; Calcium Glubionate; Calcium Gluceptate; Calcium Gluconate; Calcium Glycerophosphate and Calcium Lactate; Calcium Lactate; Calcium Lactate-Gluconate and Calcium Carbonate; Dibasic Calcium Phosphate; Tribasic Calcium Phosphate;

Electrolyte replenisher—Calcium Acetate; Calcium Chloride; Calcium Gluceptate; Calcium Gluconate Injection;

Cardiotonic—Calcium Chloride; Calcium Gluconate Injection;

Antihyperkalemic—Calcium Chloride; Calcium Gluconate Injection;

Antihypermagnesemic—Calcium Chloride; Calcium Gluceptate; Calcium Gluconate Injection;

Antacid—Calcium Carbonate;

Nutritional supplement (mineral)—Calcium Carbonate; Calcium Citrate; Calcium Glubionate, Oral; Calcium Gluceptate and Calcium Gluconate; Calcium Gluconate, Oral; Calcium Lactate; Calcium Lactate-Gluconate and Calcium Carbonate; Dibasic Calcium Phosphate; Tribasic Calcium Phosphate;

Antihyperphosphatemic—Calcium Carbonate; Calcium Citrate;

Indications

Note: Bracketed information in the Indications section refers to uses that are not included in U.S. product labeling.

Accepted

Hypocalcemia, acute (treatment)—Parenteral calcium salts (i.e., acetate, chloride, gluceptate, and gluconate) are indicated in the treatment of hypocalcemia in conditions that require a rapid increase in serum calcium-ion concentration, such as in neonatal hypocalcemic tetany; {14} tetany due to parathyroid deficiency; {13} {14} {15} {31} hypocalcemia due to ``hungry bones'' syndrome (remineralization hypocalcemia) {57} following surgery for hyperparathyroidism {57}; vitamin D deficiency; and alkalosis. Calcium salts have been used as adjunctive therapy for insect bites or stings, such as Black Widow Spider bites, {11} {13} {14} {111} and sensitivity reactions, especially when characterized by urticaria; {13} {14} and as an aid in the management of acute symptoms of lead colic. {13} {15} {46} Parenteral calcium gluconate and calcium gluceptate are also used for the prevention of hypocalcemia during exchange transfusions. {12} {14}

Electrolyte depletion (treatment)—Calcium acetate, parenteral calcium chloride, calcium gluconate, and calcium gluceptate are used in conditions that require an increase in calcium ions for electrolyte adjustment. {116}

Cardiac arrest (treatment adjunct)—Parenteral calcium chloride, {15} [or calcium gluconate] may be used also as an adjunct in cardiac resuscitation, particularly after open heart surgery, to strengthen myocardial contractions, such as following defibrillation or when there is an inadequate response to catecholamines. {111}

Hyperkalemia (treatment)—Calcium chloride {20} and parenteral calcium gluconate, {13} are used to decrease or reverse the cardiac depressant effects of hyperkalemia on electrocardiographic (ECG) function. {51} {111}

Hypermagnesemia (treatment adjunct)—Calcium chloride, [calcium gluceptate] , and calcium gluconate {13} injections have also been used as an aid in the treatment of central nervous system (CNS) depression due to overdosage of magnesium sulfate {25} {35} {111}.

Hypocalcemia, chronic (treatment){12}—Oral calcium supplements provide a source of calcium ion for treating calcium depletion occurring in conditions such as chronic hypoparathyroidism, pseudohypoparathyroidism, osteomalacia, rickets, chronic renal failure, {67} and hypocalcemia secondary to the administration of anticonvulsant medications. When chronic hypocalcemia is due to vitamin D deficiency, oral calcium salts may be administered concomitantly with vitamin D analogs. However, calcium phosphate should not be used in patients with hypoparathyroidism or renal failure, since phosphate levels may be too high and giving more phosphate would exacerbate the condition. Calcium supplements should not be used in hyperparathyroidism, unless the need for a calcium supplement is high and the patient is carefully monitored. {115} For treatment of hypocalcemia, supplementation is preferred. {120}

Calcium deficiency (prophylaxis)—Oral calcium salts are used as dietary supplemental therapy for persons who may not get enough calcium in their regular diet. However, for prophylaxis of calcium deficiency, dietary improvement, rather than supplementation, is preferred. {120} Due to increased needs, children and pregnant women are at greatest risk. Pre- and postmenopausal women; adolescents, especially girls {37} and the elderly may not receive adequate calcium in their diets. {39} However, studies have shown that supplemental calcium in postmenopausal women without functioning ovaries does not lead to increases in bone density, even in the presence of supplemental vitamin D. {78} {79} {82} Calcium supplements are used as part of the prevention and treatment of osteoporosis in patients with an inadequate calcium intake {40}. The use of calcium citrate may reduce the risk of kidney stones in susceptible patients. The use of water-soluble salts of calcium (i.e., citrate, gluconate, and lactate) may be preferable to acid-soluble salts (i.e., carbonate and phosphate) for patients with reduced stomach acid or patients taking acid-inhibiting medication, such as the histamine H 2-receptor antagonists. {37}
—Some unusual diets (e.g., reducing diets that drastically restrict food selection) may not supply minimum daily requirements of calcium. Supplementation is necessary in patients receiving total parenteral nutrition (TPN) or undergoing rapid weight loss or in those with malnutrition, because of inadequate dietary intake.
—Recommended intakes for all vitamins and most minerals are increased during pregnancy. Many physicians recommend that pregnant women receive multivitamin and mineral supplements, especially those pregnant women who do not consume an adequate diet and those in high-risk categories (i.e., women carrying more than one fetus, heavy cigarette smokers, and alcohol and drug abusers). {56} Taking excessive amounts of a multivitamin and mineral supplement may be harmful to the mother and/or fetus and should be avoided.
—Recommended intakes for all vitamins and most minerals are increased during breast-feeding. {73}

Hyperacidity (treatment)—See Calcium Carbonate, Antacids (Oral-Local).

[Hyperphosphatemia (treatment)]—Calcium carbonate is used in patients with end-stage renal failure (renal osteodystrophy) to lower serum phosphate concentrations. However, it should be used with caution in patients on chronic hemodialysis. See also Patient monitoring. Calcium citrate is also used in renal failure as a phosphate binder. {03} {21} {22}


Pharmacology/Pharmacokinetics

Physicochemical characteristics:
Molecular weight—
    Calcium acetate: 158.17 {117}
    Calcium carbonate, precipitated: 100.09 {117}
    Calcium chloride: 147.01 {117}
    Calcium citrate: 570.50 {117}
    Calcium glubionate: 610.53
    Calcium gluceptate: 490.43 {117}
    Calcium gluconate: 430.38 {117}
    Calcium lactate: 218.22 (anhydrous) {117}
    Calcium lactate-gluconate: 1551.5
    Calcium phosphate, dibasic: 136.06 {117}
    Calcium phosphate, tribasic: 503.31 {117}

Mechanism of action/Effect:

Calcium is essential for the functional integrity of the nervous, muscular, and skeletal systems. It plays a role in normal cardiac function, renal function, respiration, blood coagulation, and cell membrane and capillary permeability. Also, calcium helps to regulate the release and storage of neurotransmitters and hormones, the uptake and binding of amino acids, absorption of vitamin B 12, and gastrin secretion. {04} The major fraction (99%) of calcium is in the skeletal structure primarily as hydroxyapatite, Ca 10(PO 4) 6(OH) 2; small amounts of calcium carbonate and amorphous calcium phosphates are also present. The calcium of bone is in a constant exchange with the calcium of plasma. Since the metabolic functions of calcium are essential for life, when there is a disturbance in the calcium balance because of dietary deficiency or other causes, the stores of calcium in bone may be depleted to fill the body's more acute needs. Therefore, on a chronic basis, normal mineralization of bone depends on adequate amounts of total body calcium. {31}

Absorption:

Approximately one-fifth to one-third of orally administered calcium is absorbed in the small intestine, depending on presence of vitamin D metabolites, pH in lumen, {31} {43} and on dietary factors, such as calcium binding to fiber or phytates. {12} {31} {37} {50} Calcium absorption is increased when a calcium deficiency is present or when a patient is on a low-calcium diet. In patients with achlorhydria or hypochlorhydria, calcium absorption, especially with the carbonate salt, may be reduced. {80}

Protein binding:

Moderate, approximately 45% in plasma. {12}

Elimination:
    Renal (20%)—The amount {12} {62} excreted in the urine varies {48} with degree of calcium absorption {04} and whether there is excessive bone loss or failure of renal conservation.
    Fecal (80%)—Consists mainly of nonabsorbed calcium, with only a small amount of endogenous fecal calcium excreted. {57}


Precautions to Consider

Pregnancy/Reproduction

Pregnancy—
Studies have not been done in humans. However, problems have not been documented with intake of normal daily recommended amounts.

Studies have not been done in animals.

Second and third trimesters: Some studies have shown that calcium supplementation begun in the second trimester may be effective in lowering blood pressure in pregnant women with pregnancy-induced hypertension or pre-eclampsia, both of which may possibly be associated with increased calcium demand of the fetus during the last trimester. {08} {109}

During pregnancy, there is an increased need for calcium to calcify fetal bones and to increase the maternal skeletal mass in preparation for lactation. This need is normally met by enhanced intestinal absorption of calcium, increased vitamin D production, and a concurrent increase in calcitonin secretion, which prevents unwanted bone resorption in the maternal skeleton. {06} The maternal parathyroid glands undergo hyperplasia, producing greater amounts of parathyroid hormone {57}, which acts indirectly to increase intestinal absorption of calcium, reabsorption at the distal renal tubules, and bone calcium mobilization. However, the prescribing of calcium supplements during pregnancy may be necessary since standard prenatal vitamins along with normal intake of dairy products may not provide sufficient elemental calcium for the average pregnant woman.

Calcium acetate, calcium chloride, calcium gluceptate, calcium gluconate injection—FDA Pregnancy Category C. {116}

Other calcium salts—FDA pregnancy categories not currently included in product labeling.


Labor and delivery—

The effect of calcium chloride, calcium gluceptate, and calcium gluconate on mother and fetus during labor and delivery is unknown.

Breast-feeding

Problems in nursing babies have not been documented with intake of normal daily recommended amounts. Although some oral supplemental calcium may be distributed into breast milk, the concentration is not sufficient to produce an adverse effect in the neonate. It is not known whether calcium chloride or calcium gluconate is distributed into breast milk. {28} {35}

Pediatrics

Problems in pediatrics have not been documented with intake of normal daily recommended amounts.


Parenteral calcium preparations, especially calcium chloride {59}:

The extreme irritation and possibility of tissue necrosis and sloughing caused by intravenous injection of calcium preparations usually restricts its use in pediatric patients because of the small vasculature of this patient group.



For calcium gluceptate injection only:

It is not recommended that calcium gluceptate be administered intramuscularly to infants and children except in emergencies when the intravenous route is technically impossible, because of the possibility of severe tissue necrosis or sloughing. {70}



Geriatrics


Problems in geriatrics have not been documented with intake of normal daily recommended amounts. With advancing age, intestinal calcium absorption decreases {57}. Therefore, calcium requirements are increased in the elderly, and dosages of oral supplements may need to be adjusted accordingly. Impaired absorption may be due to low levels of active vitamin D metabolites. {57}

Drug interactions and/or related problems
The following drug interactions and/or related problems have been selected on the basis of their potential clinical significance (possible mechanism in parentheses where appropriate)—not necessarily inclusive (» = major clinical significance):


Note: Combinations containing any of the following, depending on the amount present, may also interact with this medication.
Not all interactions between calcium supplements and other oral medications have been identified in this monograph. Because the rate and/or extent of absorption of other oral medications may vary when used concurrently with calcium supplements, especially calcium carbonate, patients should be advised not to take any other oral medications within 1 to 2 hours of calcium supplements.

Alcohol or{17}{32}{119}
Caffeine, usually more than 8 cups of coffee a day{09}{12}{32} or
Tobacco{32}    (concurrent use of excessive amounts of these substances has been reported to decrease calcium absorption {12})


Antacids containing aluminum    (concurrent use with calcium citrate may enhance aluminum absorption {02} {34} {54} {63})


Calcitonin    (concurrent use with calcium supplements may antagonize the effect of calcitonin in the treatment of hypercalcemia; however, when calcitonin is prescribed for osteoporosis or Paget's disease of the bone, calcium intake should be generous to prevent hypocalcemia which might generate secondary hyperparathyroidism; calcium-containing preparations may be given 4 hours after calcitonin {03} {29} {57} {64})


Calcium-channel blocking agents    (concurrent use of these medications with calcium supplements in quantities sufficient to raise serum calcium concentrations above normal may reduce the response to verapamil and probably other calcium-channel blockers {41} {55} {68} {93} {98} {103})


» Calcium-containing preparations, other or
Magnesium-containing preparations, oral    (concurrent use with calcium supplements may increase serum calcium or magnesium concentrations in susceptible patients, mainly patients with impaired renal function, {57} {101} leading to hypercalcemia or hypermagnesemia, respectively)


» Cellulose sodium phosphate    (concurrent use with calcium supplements may decrease effectiveness of cellulose sodium phosphate in preventing hypercalciuria {90} {91})


Contraceptives, estrogen-containing, oral or
Estrogens    (concurrent use with calcium supplements may increase calcium absorption, which is used to therapeutic advantage when estrogens are prescribed for the treatment of postmenopausal osteoporosis {32} {57})


» Digitalis glycosides    (concurrent use of parenteral calcium salts with digitalis glycosides may increase the risk of cardiac arrhythmias; therefore, when the parenteral administration of calcium salts to digitalized patients is deemed necessary, caution and close electrocardiographic [ECG] monitoring are recommended {53} {103} {111})


Diuretics, thiazide    (concurrent use with large doses of calcium supplements may result in hypercalcemia because of reduced calcium excretion {97} {98} {103} {111})


» Etidronate    (concurrent use with calcium supplements may prevent absorption of etidronate; patients should be advised not to take etidronate within 2 hours of calcium supplements {92})


Fiber, found in bran, whole-grain breads and cereals or{38}{103}
Phytates, found in bran and whole-grain breads and cereals{31}{103}    (concurrent use of large amounts of fiber or phytates, especially in patients being treated for hypocalcemia {57}, with calcium supplements may reduce calcium absorption by formation of nonabsorbable complexes)


Fluoroquinolones    (concurrent use with calcium carbonate may reduce absorption by chelation of fluoroquinolones, resulting in lower serum and urine concentrations of fluoroquinolones; therefore, concurrent use is not recommended {42} {74} {75} {95} {96})


» Gallium nitrate    (concurrent use with calcium supplements may antagonize the effect of gallium nitrate {113})


Iron supplements    (concurrent use with calcium carbonate and calcium phosphate will decrease the absorption of iron {12}; iron supplements should not be taken within 1 or 2 hours of calcium carbonate or phosphate; however, when iron and calcium carbonate are present in multivitamin-with-minerals formulations, the absorption of iron is not significantly changed, possibly because the ascorbic acid in the formulation maintains the iron in the ferrous state, thus increasing its solubility and absorption {33} {100} {107} {108})


» Magnesium sulfate, parenteral    (parenteral calcium salts may neutralize effects of parenteral magnesium sulfate and should be readily available to counteract the potentially serious risk of magnesium intoxication {46} {47}; also, calcium sulfate may precipitate when a calcium salt is admixed with magnesium sulfate in the same intravenous solution {12}, although commercial nutritional solutions are formulated to avoid precipitation {45}; calcium and magnesium should be administered through separate intravenous lines if required in post-parathyroidectomy ``hungry bones'' syndrome or tetany associated with hypocalcemia and hypomagnesemia {57} {105})


Milk or milk products    (concurrent excessive and prolonged use with calcium supplements may result in the milk-alkali syndrome {97} {106})


Neuromuscular blocking agents, except succinylcholine{47}{52}    (concurrent use with parenteral calcium salts usually reverses the effects of nondepolarizing neuromuscular blocking agents; also, concurrent use with calcium salts has been reported to enhance or prolong the neuromuscular blocking action of tubocurarine {53})


» Phenytoin    (concurrent use decreases the bioavailability of both phenytoin and calcium because of possible formation of a nonabsorbable complex; patients should be advised not to take calcium supplements within 1 to 3 hours of taking phenytoin; also, enteral feeding solutions containing calcium should not be administered through a nasogastric feeding tube together with phenytoin oral suspension; a 2-hour interval should elapse between the administration of the feeding solution and of the phenytoin {12} {98} {118})


Potassium phosphates or
Potassium and sodium phosphates    (concurrent use with calcium supplements may increase potential for deposition of calcium in soft tissues if serum ionized calcium is high {16} {45} {103})


Sodium bicarbonate    (concurrent and prolonged use with calcium supplements may result in milk-alkali syndrome {77} {106})


Sodium fluoride    (concurrent use with calcium supplements may cause the calcium ions to complex with fluoride and inhibit absorption of both fluoride and calcium; however, if sodium fluoride is used with calcium supplements to treat osteoporosis, a one- to two-hour interval should elapse between doses {102} {103} {104} {111})


» Tetracyclines, oral    (concurrent use with calcium supplements may decrease absorption of tetracyclines because of possible formation of nonabsorbable complexes and increase in intragastric pH; patients should be advised not to take calcium supplements within 1 to 3 hours of taking tetracyclines {93} {94} {103})


Vitamin A    (excessive intake, more than 7500 RE or 25,000 Units per day, of vitamin A may stimulate bone loss and counteract the effects of calcium supplementation {12} and may cause hypercalcemia {57})


Vitamin D, especially calcifediol and calcitriol{103}{111}    (concurrent use of large doses of vitamin D with calcium supplements {12} may excessively increase intestinal absorption of calcium, increasing risk of chronic {12} hypercalcemia in susceptible patients; however, it may be therapeutically advantageous in elderly and high-risk groups when it is necessary to prescribe vitamin D or its derivatives with calcium; careful monitoring of serum calcium concentrations is essential during long-term therapy {57} {98})



Laboratory value alterations
The following have been selected on the basis of their potential clinical significance (possible effect in parentheses where appropriate)—not necessarily inclusive (» = major clinical significance):

With physiology/laboratory test values
Phosphate, serum    (concentrations may be decreased by excessive and prolonged calcium use)


Medical considerations/Contraindications
The medical considerations/contraindications included have been selected on the basis of their potential clinical significance (reasons given in parentheses where appropriate)— not necessarily inclusive (» = major clinical significance).


Except under special circumstances, these medications should not be used when the following medical problems exist:

For all calcium supplements:
» Hypercalcemia, primary or secondary{37}{111} or
» Hypercalciuria or{111}
» Renal calculi, calcium    (risk of exacerbation)


» Sarcoidosis    (may potentiate hypercalcemia {02})


For calcium phosphate, dibasic or tribasic, only:
» Hypoparathyroidism or
» Renal insufficiency{57}{111}    (may increase risk of hyperphosphatemia {47})


For parenteral calcium salts only:
» Digitalis toxicity    (increased risk of arrhythmias {111})


Risk-benefit should be considered when the following medical problems exist

For all calcium supplements:
» Dehydration or
Electrolyte imbalance, other    (may increase risk of hypercalcemia {02})


Diarrhea or{111}
Malabsorption, gastrointestinal, chronic    (fecal excretion of calcium may be increased, although patients with chronic diarrhea or malabsorption commonly need calcium supplements {18})


» Renal calculi, history of{111}    (risk of recurrent stone formation)


» Renal function impairment, chronic{111}    (may increase risk of hypercalcemia; however, calcium carbonate or calcium citrate may be used as a phosphate binder in renal failure {12}; also, some patients with renal failure have symptomatic hypocalcemia and need cautious treatment with calcium salts {64})


For calcium carbonate and calcium phosphate only {12}:
Achlorhydria or hypochlorhydria    (calcium absorption may be decreased unless the calcium carbonate or phosphate is taken with meals {04} {17})


For parenteral calcium salts only {69} {70} {71}:
» Cardiac function impairment{02}{05}{111}
» Ventricular fibrillation during cardiac resuscitation{05}    (increased risk of arrhythmias; however, calcium may increase strength of myocardial contraction, make fibrillation coarser, and help in electrical defibrillation, especially with concomitant hyperkalemia {12})



Patient monitoring
The following may be especially important in patient monitoring (other tests may be warranted in some patients, depending on condition; » = major clinical significance):


For hypocalcemia
Blood pressure determinations and
Electrocardiographic monitoring and{111}
Magnesium, concentrations, serum and
Parathyroid hormone (PTH) concentrations, serum and
Phosphate concentrations, serum and
Potassium concentrations, serum and
Renal function determinations    (determinations recommended at initiation of therapy and at frequent intervals during treatment of hypocalcemia)


Note: In elderly patients or patients with hypertension, blood pressure should be monitored during intravenous administration, since a transient increase in blood pressure may occur. {12}


» Calcium concentrations, serum or
» Ionized calcium concentrations, serum    (determinations recommended at frequent intervals during treatment of acute hypocalcemia to achieve normal serum calcium concentrations without exceeding them; at periodic intervals for patients on chronic hemodialysis to prevent hypercalcemia {12}; for patients with chronic renal failure not yet on dialysis who are taking calcium as a phosphate binder {59}; and during long-term therapy with oral calcium supplements. In patients with hypoparathyroidism, serum calcium concentrations should be kept in the low normal range, since significant hypercalciuria {57} may occur intermittently or as a complication {64} with higher concentrations {49}, especially if vitamin D preparations are being used concurrently; {64} serum ionized calcium concentrations are preferable to determine free and bound calcium, but may not be readily available from a reliable lab {83} {84} {85})


Calcium concentrations, urine    (urinary calcium excretion determinations are sometimes needed {12} to avoid hypercalciuria {16})




Side/Adverse Effects

Note: Side/adverse effects may be more likely to occur if oral calcium supplements are taken in much larger doses than recommended (greater than 2000 to 2500 mg a day) {12}, if they are taken for a longer period of time, or if they are taken by patients with renal function impairment or milk-alkali syndrome {86}.

The following side/adverse effects have been selected on the basis of their potential clinical significance (possible signs and symptoms in parentheses where appropriate)—not necessarily inclusive:

Those indicating need for medical attention
Incidence more frequent
With parenteral dosage forms only {69}
    
Hypotension (dizziness)
    
flushing and/or sensation of warmth or heat {116}
    
irregular heartbeat {111}
    
nausea or vomiting {111}
    
skin redness, rash, pain, or burning at injection site
    
sweating
    
tingling sensation
    
decrease in blood pressure, moderate —with calcium chloride only{18}{116}

Note: Tingling sensation may result when intravenous injection is too rapid {05} {111}; skin redness, rash, pain, or burning may indicate extravasation and can precede sloughing or necrosis of skin {12}.



Incidence rare
    
Hypercalcemic syndrome, acute (drowsiness; continuing nausea and vomiting; weakness)
    
renal calculi, calcific (difficult or painful urination)—with oral dosage forms

Early symptoms of hypercalcemia
    
Constipation, severe
    
dryness of mouth {02}{16}{20}
    
headache, continuing
    
increased thirst
    
irritability
    
loss of appetite
    
mental depression
    
metallic taste
    
unusual tiredness or weakness

Late symptoms of hypercalcemia
    
Confusion
    
drowsiness
    
high blood pressure
    
increased sensitivity of eyes or skin to light, especially in hemodialysis patients {12}
    
irregular, fast, or slow heartbeat
    
nausea and vomiting {12}
    
unusually large amount of urine or increased frequency of urination{05}{16}{20}

Note: In severe hypercalcemia, ECG changes consisting of shortened Q-T intervals are also seen.






Patient Consultation
As an aid to patient consultation, refer to Advice for the Patient, Calcium Supplements (Systemic).
In providing consultation, consider emphasizing the following selected information (» = major clinical significance):

Description of use
Description should include function in the body, signs of deficiency, and conditions that may cause deficiency


Importance of diet
Importance of proper nutrition, supplement may be needed because of inadequate dietary intake

Recommended daily intake for calcium

Importance of adequate weight-bearing exercise, especially during younger years, for building and maintaining dense bones to prevent osteoporosis in later life

Calcium content of selected foods

Importance of adequate amounts of vitamin D or exposure to sunlight for enhancement of calcium absorption; avoiding too much vitamin D

Importance of not using bonemeal or dolomite as a source of calcium because of potential lead contamination

Calcium content per tablet of supplements

Before using this dietary supplement
»   Conditions affecting use, especially:





Use in children—Use of injectable calcium preparations may cause extreme irritation and possible tissue necrosis and sloughing






Use in the elderly—Absorption is decreased; dosage adjustments may be necessary
Other medications, especially cellulose sodium phosphate, digitalis glycosides (for parenteral calcium salts only), etidronate, gallium nitrate, parenteral magnesium sulfate (for parenteral calcium salts only), phenytoin, oral tetracyclines, or other calcium-containing preparations
Other medical problems, especially hypercalcemia, hypercalciuria, calcium renal calculi, sarcoidosis, hypoparathyroidism (for calcium phosphate only), dehydration, diarrhea or malabsorption, renal function impairment, or achlorhydria or hypochlorhydria (for calcium carbonate and calcium phosphates only)

Proper use of this dietary supplement

» Proper dosing
Drinking full glass (8 ounces) of water or juice with all oral dosage forms, except when taking calcium carbonate as a phosphate binder in renal dialysis

» Proper administration of calcium carbonate or phosphate: Taking tablets 1 to 11/2 hours after meals, unless otherwise directed by physician

Proper administration of chewable tablet: Chewing tablets well before swallowing

Proper administration of syrup: Taking calcium glubionate syrup before meals; diluting syrup in water or fruit juice, if desired, for infants or children
Missed dose: If on scheduled dosing regimen—Taking as soon as possible; then going back to regular schedule

» Proper storage

Precautions while using this dietary supplement
Regular visits to physician to check progress if taking dietary supplement in large doses or if taking regularly for long period of time

» Not taking within 1 or 2 hours of other oral medication, if possible

» Avoiding concurrent use with other preparations containing significant amounts of calcium, phosphates, magnesium, or vitamin D, unless otherwise directed or approved by health care professional

» Avoiding concomitant use with certain fiber-containing foods such as bran and whole-grain breads and cereals; not eating these foods within 1 or 2 hours of taking calcium supplements

» Avoiding excessive use of alcoholic beverages, tobacco, or caffeine-containing beverages

» Importance of using calcium carbonate products labeled “USP” to avoid differences in bioavailability


Side/adverse effects
Signs of potential side effects, especially calcium renal calculi or hypercalcemia


General Dosing Information
The action of calcium supplements depends upon their content of calcium ion. The various calcium salts contain the following amounts of elemental calcium: {04} {22}

Calcium salt

Calcium
(mg/gram)

Calcium
(mEq/gram)
% Calcium
Calcium acetate
253
12.2
25.3
Calcium carbonate
400
20
40
Calcium chloride
272
13.6
27.2
Calcium citrate
211
10.5
21.1
Calcium glubionate
65
3.2
6.5
Calcium gluceptate
82
4.1
8.2
Calcium gluconate
90
4.5
9
Calcium lactate
130
6.5
13
Calcium phosphate, dibasic
230
11.5
23
Calcium phosphate, tribasic
380
19
38


The following table includes the number of tablets of each calcium salt required to provide 1000 mg of elemental calcium:

Calcium
supplement
Amount of
salt in
tablet (in
milligrams)
Amount of
calcium per
tablet (in
milligrams)
Number of
tablets to
provide 1000
milligrams of
calcium
Calcium carbonate
625
250
4
  650
260
4
  750
300
4
  835
334
3
  1250
500
2
  1500
600
2
Calcium citrate
950
200
5
Calcium gluconate
500
45
22
  650
58
17
  1000
90
11
Calcium lactate
325
42
24
  650
84
12
Calcium phosphate,
dibasic

500

115

9
Calcium phosphate,
tribasic

800
1600

304
608

4
2


Administration of calcium supplements should not preclude the use of other measures intended to correct the underlying cause of calcium depletion. {05}

In the prevention of osteoporosis, postmenopausal women are sometimes also given estrogens to prevent bone resorption and/or small doses of vitamin D(usually 400 IU per day) {12} to enhance calcium absorption {12} {19}. If estrogens are prescribed, either cyclically or continuously for women who have not undergone a hysterectomy, {80} {89} it is recommended that a progestin such as medroxyprogesterone acetate also be given to reduce or prevent the possibility of adverse endometrial changes from occurring. {12}

The Food and Drug Administration has issued warnings that bonemeal and dolomite (sometimes used as sources of calcium) may contain lead in sufficient quantities to be dangerous.
{24}
For parenteral dosage forms only
The injection should be warmed to body temperature prior to administration, unless precluded by an emergency situation. Following injection, the patient should remain recumbent for a short period of time to prevent dizziness. {25}

Parenteral calcium salts are administered by slow intravenous injection (excepting calcium glycerophosphate and calcium lactate combination which is given by intramuscular injection) {29} to prevent a high concentration of calcium from reaching the heart and causing cardiac syncope. {18} {25}

Side effects experienced by the conscious patient are often the result of too rapid a rate of intravenous administration of calcium salts. {116} Administration should be temporarily discontinued with the appearance of abnormal electrocardiogram (ECG) readings or with patient complaints of discomfort; administration may be resumed when the abnormal reading or the discomfort has disappeared. {05}

Severe necrosis, requiring skin grafting, and calcification can occur at the site of infiltration after intravenous injection, especially after push injection. {46}

Transient increases in blood pressure, especially in the elderly or patients with hypertension, may occur during intravenous administration of calcium salts.

Diet/Nutrition
Oral calcium supplements are best taken 1 to 11/2 hours after meals in 3 to 4 daily doses. However, calcium glubionate syrup should be administered before meals to enhance absorption. {12}

In the elderly, who may be more prone than younger patients to impaired stomach acid production, calcium absorption may be increased by the use of a more soluble calcium salt, such as calcium citrate, gluconate, or lactate. The poor solubility of carbonate and phosphate salts makes them less desirable as antihypocalcemic agents in patients with known achlorhydria or hypochlorhydria. {12}

Recommended dietary intakes for calcium are defined differently worldwide.


For U.S.:
The Recommended Dietary Allowances (RDAs) for vitamins and minerals are determined by the Food and Nutrition Board of the National Research Council and are intended to provide adequate nutrition in most healthy persons under usual environmental stresses. In addition, a different designation may be used by the FDA for food and dietary supplement labeling purposes, as with Daily Value (DV). DVs replace the previous labeling terminology United States Recommended Daily Allowances (USRDAs).



For Canada:
Recommended Nutrient Intakes (RNIs) for vitamins, minerals, and protein are determined by Health and Welfare Canada and provide recommended amounts of a specific nutrient while minimizing the risk of chronic diseases.

Daily recommended intakes for calcium are generally defined as follows:

Persons
U.S.
(mg)
Canada
(mg)
Infants and children
Birth to 3 years of age
400–800
250–550
4 to 6 years of age
800
600
7 to 10 years of age
800
700–1100
Adolescent and adult males
800–1200
800–1100
Adolescent and adult females
800–1200
700–1100
Pregnant females
1200
1200–1500
Breast-feeding females
1200
1200–1500


The following table indicates the calcium content of selected foods:

Food (amount)
Milligrams of calcium
Nonfat dry milk, reconstituted (1 cup)
375
Lowfat, skim, or whole milk (1 cup)
290 to 300
Yogurt (1 cup)
275 to 400
Sardines with bones (3 ounces)
370
Ricotta cheese, part skim (1/2 cup)
340
Salmon, canned, with bones (3 ounces)
285
Cheese, Swiss (1 ounce)
272
Cheese, cheddar (1 ounce)
204
Cheese, American (1 ounce)
174
Cottage cheese, lowfat (1 cup)
154
Tofu (4 ounces)
154
Shrimp (1 cup)
147
Ice milk (3/4 cup)
132



For treatment of adverse effects
Perivascular infiltration: {22}Treatment may include the following—

   • Immediate discontinuation of intravenous administration.
   • Infusion of normal saline into the area by clysis.
   • Local application of heat and elevation.
A serum calcium concentration exceeding 2.6 mmol per liter {58} (10.5 mg per l00 mL) is considered a hypercalcemic condition. Withholding additional administration of calcium and any other medications that may cause hypercalcemia usually resolves mild hypercalcemia in asymptomatic patients, when patient renal function is adequate.
When serum calcium concentrations are greater than 2.9 mmol per liter {58} (12 mg per 100 mL), immediate measures may be required with possible use of the following:

   • Hydrating with intravenous 0.9% sodium chloride injection. Forcing diuresis with furosemide or ethacrynic acid may be used to rapidly increase calcium and sodium excretion when saline overload occurs {57}.
   • Monitoring of potassium and magnesium serum concentrations and starting replacement early to prevent complications of therapy.
   • ECG monitoring and the possible {12} use of beta-adrenergic blocking agents to protect the heart against serious arrhythmias.
   • Possibly including hemodialysis, calcitonin, and corticosteroids in the treatment.
   • Determining serum calcium concentrations at frequent intervals to guide therapy adjustments. {03} {05} {20}

CALCIUM ACETATE

Summary of Differences
Category: Also used as an electrolyte replenisher.


Additional Dosing Information
See also General Dosing Information .

For intravenous use only; subcutaneous or intramuscular injection may cause severe necrosis and sloughing. {116}

Calcium acetate contains the equivalent of 253 mg of calcium ion per gram.


Parenteral Dosage Forms

CALCIUM ACETATE INJECTION

Usual adult and adolescent dose
Electrolyte replenisher or
Hypocalcemia (prophylaxis or treatment)
Intravenous infusion, as part of total parenteral nutrition solutions, the specific amount determined by individual patient need. {116}


Usual pediatric dose
Electrolyte replenisher or
Hypocalcemia (prophylaxis or treatment)
Intravenous infusion, as part of total parenteral nutrition solutions, the specific amount determined by individual patient need. {116}


Strength(s) usually available
U.S.—


40 mg (10 mg [0.5 mEq] of calcium ion) per mL (Rx)[Generic]

Canada—
Not commercially available.

Packaging and storage:
Store below 40 °C (104 °F), preferably between 15 and 30 °C (59 and 86 °F), protected from light, unless otherwise specified by manufacturer. Protect from freezing.

Incompatibilities:
Calcium acetate is precipitated by phosphates. {121}


CALCIUM CARBONATE

Summary of Differences


Category:
Also used as an antihyperphosphatemic and as an antacid (see Calcium Carbonate, Antacids [Oral-Local] ).



Precautions:
Drug interactions and/or related problems—Concurrent use with fluoroquinolones may decrease the absorption of fluoroquinolones, resulting in lower serum and urine concentrations of fluoroquinolones.

Medical considerations/contraindications—Calcium absorption may be decreased in patients with achlorhydria or hypochlorhydria, unless the supplement is taken with meals. {88}



Additional Dosing Information
See also General Dosing Information .

Calcium carbonate contains the equivalent of 400 mg of calcium ion per gram.


Oral Dosage Forms

Note: Bracketed uses in the Dosage Forms section refer to categories of use and/or indications that are not included in U.S. product labeling.

CALCIUM CARBONATE CAPSULES

Usual adult and adolescent dose
Hypocalcemia (prophylaxis)
Oral, amount based on normal daily recommended intakes:

Persons
U.S.
(mg)
Canada
(mg)
Adolescent and adult males
800–1200
800–1100
Adolescent and adult females
800–1200
700–1100
Pregnant females
1200
1200–1500
Breast-feeding females
1200
1200–1500


Hypocalcemia (treatment)
Treatment dose is individualized by prescriber based on severity of deficiency.

Antacid
See Calcium Carbonate, Antacids (Oral-Local).

[Antihyperphosphatemic]
Oral, 5 to 13 grams (2 to 5.2 grams of calcium ion) a day, in divided doses with meals.
{12}
Note: Careful titration is recommended to prevent hypercalcemia, which has been reported with doses above 2 grams of calcium ion a day. {12}



Usual pediatric dose
Dosage form not appropriate for use in children.

Strength(s) usually available
U.S.—


1.25 grams (500 mg of calcium ion) (OTC) [Calci-Mix]


1.5 grams (600 mg of calcium ion) (OTC) [Liqui-Cal] [Liquid Cal-600]

Canada—


1.25 grams (500 mg of calcium ion) (OTC) [Calsan]

Note: Some strengths of these calcium preparations may exceed the dosage range recommended by USP DI Advisory Panels based on the amount necessary to meet normal nutritional needs.


Packaging and storage:
Store below 40 °C (104 °F), preferably between 15 and 30 °C (59 and 86 °F), in a well-closed container, unless otherwise specified by manufacturer.

Auxiliary labeling:
   • Drink a full glass of water.

Note: When taking as a phosphate binder in renal dialysis, patients should not be advised to take capsules with a glass of water.



CALCIUM CARBONATE ORAL SUSPENSION USP

Usual adult and adolescent dose
Hypocalcemia (prophylaxis or treatment)
See Calcium Carbonate Capsules.

Antacid
See Calcium Carbonate, Antacids (Oral-Local).

[Antihyperphosphatemic]
Oral, 5 to 13 grams (2 to 5.2 grams of calcium ion) a day, in divided doses with meals.
{12}
Note: Careful titration is recommended to prevent hypercalcemia, which has been reported with doses above 2 grams of calcium ion a day. {12}



Usual pediatric dose
Hypocalcemia (prophylaxis)
Oral, amount based on normal daily recommended intakes:

Persons
U.S.
(mg)
Canada
(mg)
Infants and children
Birth to 3 years of age
400–800
250–550
4 to 6 years of age
800
600
7 to 10 years of age
800
700–1100


Hypocalcemia (treatment)
Treatment dose is individualized by prescriber based on severity of deficiency.


Strength(s) usually available
U.S.—


1 gram (400 mg of calcium ion) per 5 mL (OTC) [Titralac]


1.25 grams (500 mg of calcium ion) per 5 mL (OTC)[Generic]

Canada—
Not commercially available.

Note: Some strengths of these calcium preparations may exceed the dosage range recommended by USP DI Advisory Panels based on the amount necessary to meet normal nutritional needs.


Packaging and storage:
Store below 40 °C (104 °F), preferably between 15 and 30 °C (59 and 86 °F), in a well-closed container, unless otherwise specified by manufacturer.

Auxiliary labeling:
   • Shake well before using.
   • Drink a full glass of water.

Note: When taking as a phosphate binder in renal dialysis, patients should not be advised to take suspension with a glass of water.



CALCIUM CARBONATE TABLETS USP

Usual adult and adolescent dose
Hypocalcemia (prophylaxis or treatment)
See Calcium Carbonate Capsules.

Antacid
See Calcium Carbonate, Antacids (Oral-Local).

[Antihyperphosphatemic]
Oral, 5 to 13 grams (2 to 5.2 grams of calcium ion) a day, in divided doses with meals.
{12}
Note: Careful titration is recommended to prevent hypercalcemia, which has been reported with doses above 2 grams of calcium ion a day. {12}



Usual pediatric dose
See Calcium Carbonate Oral Suspension USP.

Strength(s) usually available
U.S.—


650 mg (260 mg of calcium ion) (OTC)[Generic]


667 mg (266.8 mg of calcium ion) (OTC) [Calciday 667]


1 gram (OTC) [Maalox Antacid Caplets]


1.25 grams (500 mg of calcium ion) (OTC) [BioCal][Generic]


1.5 grams (600 mg of calcium ion) (OTC) [Calcarb 600] [Calcium 600] [Cal-Plus] [Caltrate 600] [Gencalc 600] [Nephro-Calci][Generic]

Canada—


625 mg (250 mg of calcium ion) (OTC) [Apo-Cal]


1.25 grams (500 mg of calcium ion) (OTC) [Apo-Cal]


1.5 grams (600 mg of calcium ion) (OTC) [Caltrate 600][Generic]

Note: Some strengths of these calcium preparations may exceed the dosage range recommended by USP DI Advisory Panels based on the amount necessary to meet normal nutritional needs.


Packaging and storage:
Store below 40 °C (104 °F), preferably between 15 and 30 °C (59 and 86 °F), unless otherwise specified by manufacturer. Store in a well-closed container.

Auxiliary labeling:
   • Drink a full glass of water.

Note: When taking as a phosphate binder in renal dialysis, patients should not be advised to take tablets with a glass of water.



CALCIUM CARBONATE TABLETS (CHEWABLE) USP

Usual adult and adolescent dose
Hypocalcemia (prophylaxis or treatment)
See Calcium Carbonate Capsules.

Antacid
See Calcium Carbonate, Antacids (Oral-Local).

[Antihyperphosphatemic]
Oral, 5 to 13 grams (2 to 5.2 grams of calcium ion) a day, in divided doses with meals.
{12}
Note: Careful titration is recommended to prevent hypercalcemia, which has been reported with doses above 2 grams of calcium ion a day. {12}



Usual pediatric dose
See Calcium Carbonate Oral Suspension USP.

Strength(s) usually available
U.S.—


350 mg (140 mg calcium ion) (OTC) [Amitone]


420 mg (168 mg of calcium ion) (OTC) [Calcilac] [Calglycine] [Mallamint] [Titralac]


500 mg (200 mg of calcium ion) (OTC) [Chooz] [Dicarbosil] [Tums]


550 mg (220 mg of calcium ion) (OTC) [Rolaids Calcium Rich]


750 mg (300 mg of calcium ion) (OTC) [Caltrate Jr] [Tums E-X]


850 mg (340 mg calcium ion) (OTC) [Alka-Mints]


1.25 grams (500 mg of calcium ion) (OTC) [Calci-Chew] [OsCal 500 Chewable] [Tums 500]


1.5 grams (600 mg calcium ion) (OTC) [Calcium 600]

Canada—


500 mg (200 mg of calcium ion) (OTC) [Tums Regular Strength]


750 mg (300 mg of calcium ion) (OTC) [Tums Extra Strength]


1250 mg (500 mg of calcium ion) (OTC) [Calsan]

Note: Some strengths of these calcium preparations may exceed the dosage range recommended by USP DI Advisory Panels based on the amount necessary to meet normal nutritional needs.


Packaging and storage:
Store below 40 °C (104 °F), preferably between 15 and 30 °C (59 and 86 °F), unless otherwise specified by manufacturer. Store in a well-closed container.

Auxiliary labeling:
   • Chew tablets before swallowing.
   • Drink a full glass of water.

Note: When taking as a phosphate binder in renal dialysis, patients should not be advised to take tablets with a glass of water.



CALCIUM CARBONATE(OYSTER-SHELL DERIVED)TABLETS

Usual adult and adolescent dose
Hypocalcemia (prophylaxis or treatment)
See Calcium Carbonate Capsules.

Antacid
See Calcium Carbonate, Antacids (Oral-Local).

[Antihyperphosphatemic]
Oral, 5 to 13 grams (2 to 5.2 grams of calcium ion) a day, in divided doses with meals.
{12}
Note: Careful titration is recommended to prevent hypercalcemia, which has been reported with doses above 2 grams of calcium ion a day. {12}



Usual pediatric dose
Hypocalcemia (prophylaxis or treatment)
See Calcium Carbonate Oral Suspension USP.


Strength(s) usually available
U.S.—


1.25 grams (500 mg of calcium ion) (OTC) [Os-Cal 500] [Oysco] [Oyst-Cal 500] [Oystercal 500][Generic]


1.562 grams (625 mg of calcium ion) (OTC)[Generic]

Canada—


625 mg (250 mg of calcium ion) (OTC) [Os-Cal]


1.25 grams (500 mg of calcium ion) (OTC) [Calcite 500] [Nu-Cal] [Os-Cal]

Note: Some strengths of these calcium preparations may exceed the dosage range recommended by USP DI Advisory Panels based on the amount necessary to meet normal nutritional needs.


Packaging and storage:
Store below 40 °C (104 °F), preferably between 15 and 30 °C (59 and 86 °F), unless otherwise specified by manufacturer. Store in a well-closed container.

Auxiliary labeling:
   • Drink a full glass of water.

Note: When taking as a phosphate binder in renal dialysis, patients should not be advised to take tablets with a glass of water.



CALCIUM CARBONATE(OYSTER-SHELL DERIVED)TABLETS (CHEWABLE)

Usual adult and adolescent dose
Antacid
See Calcium Carbonate, Antacids (Oral-Local).

Hypocalcemia (prophylaxis or treatment)
See Calcium Carbonate Capsules.

[Antihyperphosphatemic]
Oral, 5 to 13 grams (2 to 5.2 grams of calcium ion) a day, in divided doses with meals.
{12}
Note: Careful titration is recommended to prevent hypercalcemia, which has been reported with doses above 2 grams of calcium ion a day. {12}



Usual pediatric dose
See Calcium Carbonate Oral Suspension USP.

Strength(s) usually available
U.S.—


1.25 grams (500 mg of calcium ion) (OTC) [Oysco 500 Chewable][Generic]

Canada—


1.25 grams (500 mg of calcium ion) (OTC) [Os-Cal Chewable]


1.875 grams (750 mg of calcium ion) (OTC) [Os-Cal Chewable]

Note: Some strengths of these calcium preparations may exceed the dosage range recommended by USP DI Advisory Panels based on the amount necessary to meet normal nutritional needs.


Packaging and storage:
Store below 40 °C (104 °F), preferably between 15 and 30 °C (59 and 86 °F), unless otherwise specified by manufacturer. Store in a well-closed container.

Auxiliary labeling:
   • Chew tablets before swallowing.
   • Drink a full glass of water.

Note: When taking as a phosphate binder in renal dialysis, patients should not be advised to take tablets with a glass of water.



CALCIUM CHLORIDE

Summary of Differences
Category: Also used as an electrolyte replenisher, a cardiotonic, an antihyperkalemic, and an antihypermagnesemic.

Precautions: Pediatrics—Parenteral calcium chloride use is usually restricted in pediatric patients due to possibility of irritation in small vasculature.

Side/adverse effects: Causes peripheral vasodilation with moderate decrease in blood pressure.

General dosing information: Has three times as much calcium per mL as calcium gluconate injection. {12}


Additional Dosing Information
See also General Dosing Information .

For intravenous use only; not to be administered intramuscularly, intramyocardially, subcutaneously, or permitted to extravasate into any body tissue; may cause severe {46} tissue necrosis and/or sloughing and abscess formation {46}.

Injected through a small-bore needle inserted into a large vein to minimize irritation.

Calcium chloride contains 272 mg of calcium ion per gram.


Parenteral Dosage Forms

CALCIUM CHLORIDE INJECTION USP

Usual adult dose
Hypocalcemia (prophylaxis)
Intravenous infusion, as part of total parenteral nutrition solutions, the specific amount determined by individual patient need.

Hypocalcemia (treatment) or
Electrolyte replenisher
Intravenous, 500 mg to 1 gram (136 to 272 mg {60} of calcium ion) administered slowly at a rate not to exceed 0.5 mL (13.6 mg of calcium ion) to {12} 1 mL (27.2 mg of calcium ion) a minute, the dosage being repeated at intervals of one to three days as indicated by patient response and serum calcium concentrations.

Note: For use in cases such as hungry bones syndrome, some clinicians recommend that calcium chloride be diluted in saline or dextrose and given by continuous intravenous infusion at a dosage of 0.5 to 1 mg per minute (up to 2 or more mg per minute). The rate and/or concentration can be adjusted until oral calcium supplements can be given. {109} {110}


Cardiotonic
Intravenous, 500 mg to 1 gram (136 to 272 mg of calcium ion) administered at a rate not to exceed 1 mL (27.2 mg of calcium ion) a minute.
Intraventricular, 200 to 800 mg (54.4 to 217.6 mg of calcium ion) {69} administered directly into cavity as a single dose.

Note: Injection into the cardiac muscle must be avoided. {46}


Antihyperkalemic
Dosage must be titrated by constant monitoring of ECG changes during administration. {69}

Antihypermagnesemic
Intravenous, initially 500 mg (136 mg of calcium ion) repeated as indicated by patient response. {69}


Usual pediatric dose
Hypocalcemia (treatment) or
Electrolyte replenisher
Intravenous, 25 mg (6.8 mg of calcium ion) per kg of body weight administered slowly. {69}

Note: Calcium chloride injection is rarely used in pediatric patients, since a less irritating salt is preferred for use in the small vasculature.



Strength(s) usually available
U.S.—


100 mg (27.2 mg [1.36 mEq] of calcium ion) per mL (Rx)[Generic]

Canada—


100 mg (27.2 mg [1.36 mEq] of calcium ion) per mL (Rx) [Calciject][Generic]

Packaging and storage:
Store below 40 °C (104 °F), preferably between 15 and 30 °C (59 and 86 °F), unless otherwise specified by manufacturer. Protect from freezing.

Incompatibilities:
Calcium chloride is precipitated by carbonates or bicarbonates, phosphates, sulfates, and tartrates. {26}


CALCIUM CITRATE

Summary of Differences


Indications:
May reduce risk of kidney stones in susceptible patients.

Also used to treat hyperphosphatenia in renal osteodystrophy.



Additional Dosing Information
See also General Dosing Information .

Calcium citrate contains 211 mg of calcium ion per gram.


Oral Dosage Forms

CALCIUM CITRATE TABLETS

Usual adult and adolescent dose
Hypocalcemia (prophylaxis)
Oral, amount based on normal daily recommended intakes:

Persons
U.S.
(mg)
Canada
(mg)
Adolescent and adult males
800–1200
800–1100
Adolescent and adult females
800–1200
700–1100
Pregnant females
1200
1200–1500
Breast-feeding females
1200
1200–1500


Hypocalcemia (treatment)
Treatment dose is individualized by prescriber based on severity of deficiency.


Usual pediatric dose
Dosage form not appropriate for use in children.

Strength(s) usually available
U.S.—


950 mg (200 mg of calcium ion) (OTC) [Citracal]

Canada—
Not commercially available.

Note: The strength of this calcium preparation may exceed the dosage range recommended by USP DI Advisory Panels based on the amount necessary to meet normal nutritional needs.


Packaging and storage:
Store below 40 °C (104 °F), preferably between 15 and 30 °C (59 and 86 °F), in a well-closed container, unless otherwise specified by manufacturer. {01} {30}

Auxiliary labeling:
   • Drink a full glass of water.


CALCIUM CITRATE EFFERVESCENT TABLETS

Usual adult and adolescent dose
See Calcium Citrate Tablets.

Usual pediatric dose
Hypocalcemia (prophylaxis)
Oral, amount based on normal daily recommended intakes:

Persons
U.S.
(mg)
Canada
(mg)
Infants and children
Birth to 3 years of age
400–800
250–550
4 to 6 years of age
800
600
7 to 10 years
800
700–1100


Hypocalcemia (treatment)
Treatment dose is individualized by prescriber based on severity of deficiency.


Strength(s) usually available
U.S.—


2.38 grams (500 mg calcium ion) (OTC) [Citracal Liquitabs]

Canada—
Not commercially available.

Packaging and storage:
Store below 40°C (104°F), preferably between 15 and 30 °C (59 and 86 °F), unless otherwise specified by manufacturer. Store in a tight container or original foil packaging.

Auxiliary labeling:
   • Take dissolved in glass of water.


CALCIUM GLUBIONATE


Oral Dosage Forms

CALCIUM GLUBIONATE SYRUP USP

Usual adult and adolescent dose
Hypocalcemia (prophylaxis)
Oral, amount based on normal daily recommended intakes:

Persons
U.S.
(mg)
Canada
(mg)
Adolescent and adult males
800–1200
800–1100
Adolescent and adult females
800–1200
700–1100
Pregnant females
1200
1200–1500
Breast-feeding females
1200
1200–1500


Hypocalcemia (treatment)
Treatment dose is individualized by prescriber based on severity of deficiency


Usual pediatric dose
Hypocalcemia (prophylaxis)
Oral, amount based on normal daily recommended intakes:

Persons
U.S.
(mg)
Canada
(mg)
Infants and children
Birth to 3 years of age
400–800
250–550
4 to 6 years of age
800
600
7 to 10 years
800
700–1100


Hypocalcemia (treatment)
Treatment dose is individualized by prescriber based on severity of deficiency.


Strength(s) usually available
U.S.—


1.8 grams (115 mg of calcium ion) per 5 mL (OTC) [Calcionate] [Neo-Calglucon]

Canada—


1.2 grams calcium lactobionate, 530 mg calcium gluconate (110 mg of calcium ion) per 5 mL (OTC) [Calcium-Sandoz{111}]

Note: Some strengths of these calcium preparations may exceed the dosage range recommended by USP DI Advisory Panels based on the amount necessary to meet normal nutritional needs.


Packaging and storage:
Store below 30 °C (86 °F) preferably between 15 and 30 °C (59 and 86 °F), unless otherwise specified by manufacturer. Store in a tight container. Protect from freezing.


CALCIUM GLUCEPTATE

Summary of Differences
Category: Also used as an electrolyte replenisher and as an antihypermagnesemic.

Precautions: Pediatrics—Administered intramuscularly to infants and children only in emergencies when intravenous route is technically impossible.


Additional Dosing Information
See also General Dosing Information .

Calcium gluceptate contains 82 mg of calcium ion per gram.

May also be administered intramuscularly to adults.


Parenteral Dosage Forms

Note: Bracketed uses in the Dosage Forms section refer to categories of use and/or indications that are not included in U.S. product labeling.

CALCIUM GLUCEPTATE INJECTION USP

Usual adult and adolescent dose
Hypocalcemia (prophylaxis)
Intravenous infusion, as part of total parenteral nutrition solutions, the specific amount determined by individual patient need.

Hypocalcemia (treatment) or
Electrolyte replenisher
Intramuscular, 440 mg to 1.1 gram (36 to 90 mg of calcium ion). {70}

Note: When a dose of 5 mL (90 mg of calcium ion) or more is administered, injection should be in the gluteal region. {70}

Intravenous, 1.1 to 4.4 grams (90 to 360 mg of calcium ion) administered slowly at a rate not to exceed 2 mL (36 mg of calcium ion) a minute. {70}

[Antihypermagnesemic]
Intravenous, initially 1.2 to 2.4 grams (98 to 196 mg of calcium ion) administered slowly at a rate not to exceed 2 mL (36 mg of calcium ion) a minute.


Usual pediatric dose
Hypocalcemia (prophylaxis)
Intravenous infusion, part of total parenteral nutrition solutions, the specific amount determined by individual patient need.

Hypocalcemia (treatment)
Intramuscular, 440 mg to 1.1 gram (36 to 90 mg of calcium ion).

Note: Calcium gluceptate may be administered intramuscularly to infants and children only in emergencies when intravenous administration is impossible.
When a dose of 5 mL (90 mg of calcium ion) or more is administered to infants, injection should be administered in the lateral thigh.

Intravenous, 440 mg to 1.1 gram (36 to 90 mg of calcium ion) as a single dose, administered at a rate not to exceed 2 mL (36 mg of calcium ion) a minute.

Exchange transfusions in newborns
Intravenous, 110 mg (9 mg of calcium ion) after every 100 mL of blood exchanged. {70}


Strength(s) usually available
U.S.—


220 mg (18 mg [0.9 mEq] of calcium ion) per mL (Rx)[Generic]

Canada—
Not commercially available.

Packaging and storage:
Store below 38 °C (100 °F), preferably between 15 and 30 °C (59 and 86 °F), unless otherwise specified by manufacturer. Store in a tight container. Protect from freezing.

Stability:
Do not use if crystals are present.

Discard unused portion.

Incompatibilities:
Calcium gluceptate is precipitated by carbonates or bicarbonates, phosphates, sulfates, and tartrates. {26}


CALCIUM GLUCEPTATE AND CALCIUM GLUCONATE


Oral Dosage Forms

CALCIUM GLUCEPTATE AND CALCIUM GLUCONATE ORAL SOLUTION

Usual adult and adolescent dose
Hypocalcemia (prophylaxis)
Oral, amount based on normal daily recommended intakes:

Persons
U.S.
(mg)
Canada
(mg)
Adolescent and adult males
800–1200
800–1100
Adolescent and adult females
800–1200
700–1100
Pregnant females
1200
1200–1500
Breast-feeding females
1200
1200–1500


Hypocalcemia (treatment)
Treatment dose is individualized by prescriber based on severity of deficiency.


Usual pediatric dose
Hypocalcemia (prophylaxis)
Oral, amount based on normal daily recommended intakes:

Persons
U.S.
(mg)
Canada
(mg)
Infants and children
Birth to 3 years of age
400–800
250–550
4 to 6 years of age
800
600
7 to 10 years
800
700–1100


Hypocalcemia (treatment)
Treatment dose is individualized by prescriber based on severity of deficiency.


Strength(s) usually available
U.S.—
Not commercially available.

Canada—


660 mg calcium gluceptate, and 560 mg calcium gluconate (total of 100 mg of calcium ion) per 5 mL (OTC) [Calcium Stanley]

Note: The strength of this calcium preparation may exceed the dosage range recommended by USP DI Advisory Panels based on the amount necessary to meet normal nutritional needs.


Packaging and storage:
Store below 40 °C (104 °F), preferably between 15 and 30 °C (59 and 86 °F), unless otherwise specified by manufacturer.


CALCIUM GLUCONATE

Summary of Differences
Category: Injection may also be used as an electrolyte replenisher, a cardiotonic, an antihyperkalemic, and an antihypermagnesemic.


Additional Dosing Information
See also General Dosing Information .

Calcium gluconate injection is for intravenous use only; it is not to be administered intramuscularly, intramyocardially, subcutaneously, or permitted to extravasate into any body tissue; may cause severe tissue necrosis and/or sloughing, and abscess formation {46}.

Calcium gluconate contains 90 mg of calcium ion per gram.


Oral Dosage Forms

CALCIUM GLUCONATE TABLETS USP

Usual adult and adolescent dose
Hypocalcemia (prophylaxis)
Oral, amount based on normal daily recommended intakes:

Persons
U.S.
(mg)
Canada
(mg)
Adolescent and adult males
800–1200
800–1100
Adolescent and adult females
800–1200
700–1100
Pregnant females
1200
1200–1500
Breast-feeding females
1200
1200–1500


Hypocalcemia (treatment)
Treatment dose is individualized by prescriber based on severity of deficiency.


Usual pediatric dose
Dosage form not appropriate for use in children.

Strength(s) usually available
U.S.—


325 mg (OTC)[Generic]


500 mg (45 mg of calcium ion) (OTC)[Generic]


650 mg (58.5 mg of calcium ion) (OTC)[Generic]


975 mg (87.75 mg of calcium ion) (OTC)[Generic]


1 gram (90 mg of calcium ion) (OTC)[Generic]

Canada—


650 mg (60 mg of calcium ion) (OTC)[Generic]

Note: Some strengths of these calcium preparations may exceed the dosage range recommended by USP DI Advisory Panels based on the amount necessary to meet normal nutritional needs.



CALCIUM GLUCONATE TABLETS (CHEWABLE) USP

Usual adult and adolescent dose
Hypocalcemia (prophylaxis)
Oral, amount based on normal daily recommended intakes:

Persons
U.S.
(mg)
Canada
(mg)
Adolescent and adult males
800–1200
800–1100
Adolescent and adult females
800–1200
700–1100
Pregnant females
1200
1200–1500
Breast-feeding females
1200
1200–1500


Hypocalcemia (treatment)
Treatment dose is individualized by prescriber based on severity of deficiency.


Usual pediatric dose
Hypocalcemia (prophylaxis)
Oral, amount based on normal daily recommended intakes:

Persons
U.S.
(mg)
Canada
(mg)
Infants and children
Birth to 3 years of age
400–800
250–550
4 to 6 years of age
800
600
7 to 10 years
800
700–1100


Hypocalcemia (treatment)
Treatment dose is individualized by prescriber based on severity of deficiency.


Strength(s) usually available
U.S.—


650 mg (58.5 mg of calcium ion) (OTC)[Generic]


1 gram (90 mg of calcium ion) (OTC)[Generic]

Canada—
Not commercially available.

Note: Some strengths of these calcium preparations may exceed the dosage range recommended by USP DI Advisory Panels based on the amount necessary to meet normal nutritional needs.


Packaging and storage:
Store below 40 °C (104 °F), preferably between 15 and 30 °C (59 and 86 °F), unless otherwise specified by manufacturer. Store in a well-closed container.

Auxiliary labeling:
   • Chew tablets before swallowing.
   • Drink a full glass of water.



Parenteral Dosage Forms

Note: Bracketed uses in the Dosage Forms section refer to categories of use and/or indications that are not included in U.S. product labeling.

CALCIUM GLUCONATE INJECTION USP

Usual adult dose
Hypocalemia (prophylaxis)
Intravenous infusion, as part of total parenteral nutrition solutions, the specific amount determined by individual patient need.

Hypocalcemia (treatment) or
Electrolyte replenisher
Intravenous, 970 mg (94.7 mg of calcium ion), administered slowly at a rate not to exceed 5 mL (47.5 mg of calcium ion) a minute. The dosage may be repeated, if necessary, until tetany is controlled. {71}

Note: For use in cases such as hungry bones syndrome, some clinicians recommend that calcium gluconate be diluted in isotonic solution and given by continuous intravenous infusion at a dosage of 0.5 to 1 mg per minute (up to 2 or more mg per minute). The rate and/or concentration can be adjusted until oral calcium supplements can be given. {109} {110}


Antihyperkalemic
Intravenous, 1 to 2 {12} grams (94.7 to 189 mg of calcium ion), administered slowly at a rate not to exceed 5 mL (47.5 mg of calcium ion) a minute, the dosage being titrated and adjusted by constant monitoring of ECG changes during administration. {27}

[Antihypermagnesemic]
Intravenous, 1 to 2 grams (94.7 to 189 mg of calcium ion), administered at a rate not to exceed 5 mL (47.5 mg of calcium ion) a minute.


Usual adult prescribing limits
15 grams (1.42 gram of calcium ion) a day. {71}

Usual pediatric dose
Hypocalcemia (prophylaxis)
Intravenous infusion, as part of total parenteral nutrition solutions, the specific amount determined by individual patient need.

Hypocalcemia (treatment)
Intravenous, 200 to 500 mg (19.5 to 48.8 mg of calcium ion) as a single dose, administered slowly at a rate not to exceed 5 mL (47.5 mg of calcium ion) a minute, repeated if necessary until tetany is controlled. {71}

Exchange transfusions in newborns
Intravenous, 97 mg (9.5 mg of calcium ion) administered after every 100 mL of citrated blood exchanged. {28} {71}


Strength(s) usually available
U.S.—


100 mg (9.3 mg [0.465 mEq] of calcium ion) per mL (Rx)[Generic]

Canada—


100 mg (9.3 mg [0.465 mEq] of calcium ion) per mL (Rx)[Generic]

Packaging and storage:
Store below 40 °C (104 °F), preferably between 15 and 30 °C (59 and 86 °F), unless otherwise specified by manufacturer. Protect from freezing.

Stability:
Only clear solutions should be administered. If any crystals form, they may be redissolved by warming to 30 to 40 °C (86 to 104 °F).

Incompatibilities:
Calcium gluconate is precipitated by carbonates or bicarbonates, phosphates, sulfates, and tartrates. {26}

Additional information:
Injection also contains 3.5 mg of calcium d-saccharate tetrahydrate per mL for stabilization. {28}


CALCIUM GLYCEROPHOSPHATE AND CALCIUM LACTATE


Additional Dosing Information
See also General Dosing Information .

Intramuscular administration does not produce inflammation or sloughing at site of injection.


Parenteral Dosage Forms

CALCIUM GLYCEROPHOSPHATE AND CALCIUM LACTATE INJECTION

Usual adult and adolescent dose
Hypocalcemia (prophylaxis)
Intravenous infusion, as part of total parenteral nutrition solutions, the specific amount determined by individual patient need.

Hypocalcemia (treatment)
Intramuscular, initially 10 mL one or two times a week for four to five weeks, the dosage being repeated as needed to raise serum calcium concentrations.


Usual pediatric dose
Dosage has not been established.

Strength(s) usually available
U.S.—


5 mg of calcium glycerophosphate and 5 mg of calcium lactate (0.08 mEq of calcium ion) per mL (Rx) [Calphosan (in sodium chloride solution) (0.25% phenol)]

Canada—
Not commercially available.

Packaging and storage:
Store below 40 °C (104 °F), preferably between 15 and 30 °C (59 and 86 °F), unless otherwise specified by manufacturer. Protect from light. Protect from freezing.

Note: May also be administered intravenously or subcutaneously because of neutral pH (approximately 7).


Additional information:
Contains phenol 0.25% as a preservative.


CALCIUM LACTATE


Additional Dosing Information
See also General Dosing Information .

Calcium lactate contains 130 mg of calcium ion per gram.


Oral Dosage Forms

CALCIUM LACTATE TABLETS USP

Usual adult and adolescent dose
Hypocalcemia (prophylaxis)
Oral, amount based on normal daily recommended intakes:

Persons
U.S.
(mg)
Canada
(mg)
Adolescent and adult males
800–1200
800–1100
Adolescent and adult females
800–1200
700–1100
Pregnant females
1200
1200–1500
Breast-feeding females
1200
1200–1500


Hypocalcemia (treatment)
Treatment dose is individualized by prescriber based on severity of deficiency.


Usual pediatric dose
Hypocalcemia (prophylaxis)
Oral, amount based on normal daily recommended intakes:

Persons
U.S.
(mg)
Canada
(mg)
Infants and children
Birth to 3 years of age
400–800
250–550
4 to 6 years of age
800
600
7 to 10 years
800
700–1100


Hypocalcemia (treatment)
Treatment dose is individualized by prescriber based on severity of deficiency.


Strength(s) usually available
U.S.—


325 mg (42.25 mg of calcium ion) (OTC)[Generic]


650 mg (84.5 mg of calcium ion) (OTC)[Generic]

Canada—


650 mg (84.5 mg of calcium ion) (OTC)[Generic]

Note: Some strengths of these calcium preparations may exceed the dosage range recommended by USP DI Advisory Panels based on the amont necessary to meet normal nutritional needs.


Packaging and storage:
Store below 40 °C (104 °F), preferably between 15 and 30 °C (59 and 86 °F), unless otherwise specified by manufacturer. Store in a tight container.

Auxiliary labeling:
   • Drink a full glass of water.


CALCIUM LACTATE-GLUCONATE AND CALCIUM CARBONATE


Oral Dosage Forms

CALCIUM LACTATE-GLUCONATE AND CALCIUM CARBONATE EFFERVESCENT TABLETS

Usual adult and adolescent dose
Hypocalcemia (prophylaxis)
Oral, amount based on normal daily recommended intakes:

Persons
U.S.
(mg)
Canada
(mg)
Adolescent and adult males
800–1200
800–1100
Adolescent and adult females
800–1200
700–1100
Pregnant females
1200
1200–1500
Breast-feeding females
1200
1200–1500


Hypocalcemia (treatment)
Treatment dose is individualized by prescriber based on severity of deficiency.


Usual pediatric dose
Hypocalcemia (prophylaxis)
Oral, amount based on normal daily recommended intakes:

Persons
U.S.
(mg)
Canada
(mg)
Infants and children
Birth to 3 years of age
400–800
250–550
4 to 6 years of age
800
600
7 to 10 years
800
700–1100


Hypocalcemia (treatment)
Treatment dose is individualized by prescriber based on severity of deficiency.


Strength(s) usually available
U.S.—
Not commercially available.

Canada—


2.37 grams calcium lactate-gluconate, and 1.75 grams calcium carbonate (total of 1000 mg of calcium ion) (OTC) [Gramcal]{111}


2.94 grams calcium lactate-gluconate, and 300 mg calcium carbonate (total of 500 mg of calcium ion) (OTC) [Calcium-Sandoz Forte]

Note: Some strengths of these calcium preparations may exceed the dosage range recommended by USP DI Advisory Panels based on the amount necessary to meet normal nutritional needs.


Packaging and storage:
Store below 40 °C (104 °F), preferably between 15 and 30 °C (59 and 86 °F), in a well-closed container, unless otherwise specified by manufacturer.


DIBASIC CALCIUM PHOSPHATE

Summary of Differences


Medical considerations/contraindications:
Calcium absorption may be decreased in patients with achlorhydria or hypochlorhydria, unless the supplement is taken with meals.

Risk of hyperphosphatemia may be increased in patients with hypoparathyroidism or renal insufficiency. {80}



Additional Dosing Information
See also General Dosing Information.

Dibasic calcium phosphate contains 230 mg of calcium ion per gram.


Oral Dosage Forms

DIBASIC CALCIUM PHOSPHATE TABLETS USP

Usual adult and adolescent dose
Hypocalcemia (prophylaxis)
Oral, amount based on normal daily recommended intakes:

Persons
U.S.
(mg)
Canada
(mg)
Adolescent and adult males
800–1200
800–1100
Adolescent and adult females
800–1200
700–1100
Pregnant females
1200
1200–1500
Breast-feeding females
1200
1200–1500


Hypocalcemia (treatment)
Treatment dose is individualized by prescriber based on severity of deficiency.


Usual pediatric dose
Hypocalcemia (prophylaxis)
Oral, amount based on normal daily recommended intakes:

Persons
U.S.
(mg)
Canada
(mg)
Infants and children
Birth to 3 years of age
400–800
250–550
4 to 6 years of age
800
600
7 to 10 years
800
700–1100


Hypocalcemia (treatment)
Treatment dose is individualized by prescriber based on severity of deficiency.


Strength(s) usually available
U.S.—


500 mg (115 mg of calcium ion) (OTC)[Generic]

Canada—
Not commercially available.

Note: The strength of this calcium preparation may exceed the dosage range recommended by USP DI Advisory Panels based on the amount necessary to meet normal nutritional needs.


Packaging and storage:
Store below 40 °C (104 °F), preferably between 15 and 30 °C (59 and 86 °F), unless otherwise specified by manufacturer. Store in a well-closed container.

Auxiliary labeling:
   • Drink a full glass of water.


TRIBASIC CALCIUM PHOSPHATE

Summary of Differences


Medical considerations/contraindications:
Calcium absorption may be decreased in patients with achlorhydria or hypochlorhydria, unless the supplement is taken with meals.

Risk of hyperphosphatemia may be increased in patients with hypoparathyroidism or renal insufficiency. {80}



Additional Dosing Information
See also General Dosing Information .

Tribasic calcium phosphate contains 380 mg of calcium ion per gram.


Oral Dosage Forms

TRIBASIC CALCIUM PHOSPHATE TABLETS

Usual adult dose
Hypocalcemia (prophylaxis)
Oral, amount based on normal daily recommended intakes:

Persons
U.S.
(mg)
Canada
(mg)
Adolescent and adult males
800–1200
800–1100
Adolescent and adult females
800–1200
700–1100
Pregnant females
1200
1200–1500
Breast-feeding females
1200
1200–1500


Hypocalcemia (treatment)
Treatment dose is individualized by prescriber based on severity of deficiency.


Usual pediatric dose
Hypocalcemia (prophylaxis)
Oral, amount based on normal daily recommended intakes:

Persons
U.S.
(mg)
Canada
(mg)
Infants and children
Birth to 3 years of age
400–800
250–550
4 to 6 years of age
800
600
7 to 10 years
800
700–1100


Hypocalcemia (treatment)
Treatment dose is individualized by prescriber based on severity of deficiency.


Strength(s) usually available
U.S.—


1.6 grams (600 mg of calcium ion) (OTC) [Posture]

Canada—
Not commercially available.

Note: The strength of this calcium preparation may exceed the dosage range recommended by USP DI Advisory Panels based on the amount necessary to meet normal nutritional needs.


Packaging and storage:
Store below 40 °C (104 °F), preferably between 15 and 30 °C (59 and 86 °F), in a well-closed container, unless otherwise specified by manufacturer.

Auxiliary labeling:
   • Drink a full glass of water.



Revised: 07/18/1995



References
  1. Manufacturer private communication.
  1. Salina P, Frech W, Ekstrom L et al. Dietary citric acid enhances absorption of aluminum in antacids. Clin Chem 1986; 32(3): 539-41.
  1. Wyngaarden J, Smith L, editors. Cecil's Textbook of Medicine. 18th ed. Philadelphia: W.B. Saunders, 1988.
  1. McEvoy GK, editor. AHFS Drug information 90. Bethesda, MD: American Society of Hospital Pharmacists, 1985.
  1. Knoben J, Anderson P. Handbook of clinical drug data. Hamilton IL: Drug Intelligence Publications, Inc., 1993: 250.
  1. Smith R el al. Osteoporosis of Pregnancy. The Lancet, May 25, 1985: 1178.
  1. Rayburn WF, Zuspan FP. Drug therapy in obstetrics and gynecology. 1982.
  1. Belizan J, Villar J, Zalazar A, et al. Preliminary evidence of the effect of calcium supplementation on blood pressure in normal pregnant women. Am J Obstet Gynecol 1983; 146: 175-80.
  1. FDA Consumer, Sept. 1984.
  1. Drug Interactions, 5th Ed, 1985; Hansten, PD. 397.
  1. Dreisbach RH, Robertson WO. Handbook of poisoning: Prevention, diagnosis, & treatment. 12th ed. Norwalk CT: Appleton & Lange, 1987: 484.
  1. Panelist comment.
  1. Calcium gluconate product information (LyphoMed—U.S.) Rec 6/93, Rev 10/92.
  1. Calcium gluceptate product information (Lilly—U.S.) Rec 6/90, Rev 3/90.
  1. Calcium chloride product information (LyphoMed—U.S.) Rec 12/91, Rev 6/91.
  1. McFadden E et al. Hypocalcemia: A medical emergency. Am J Nurs February 1983.
  1. Recker R. Calcium absorption and achlorhydria. NEJM 1985; 313: 70-3.
  1. Gilman AG, Goodman LS, Rall TW, Murad F, editors. Goodman and Gilman's the pharmocological basis of therapeutics. 6th ed. New York: Macmillan, 1980.
  1. Calcium Gluconate product information, Rev 8/85.
  1. Calcium chloride product information (Astra—U.S.) Rec 10/93, Rev 8/93.
  1. Fournier A. Control of predialytic hyperphosphatemia by oral calcium acetate and calcium carbonate. Nephron 1992; 60: 6-11.
  1. Taylor J, Henderson I, Stewart W et al. Calcium carbonate 1250 mg/1260 mg: and effective phosphate binder. Scot Med J 1990; 35: 45-7.
  1. FDA Consumer July-August, 1981.
  1. FDA BULLETIN.
  1. Ellenhorn MJ, Barceloux DG. Medical toxicology. Diagnosis and treatment of human poisoning. New York: Elsevier, 1988: 1047.
  1. Gennaro AR, editor. Remington's pharmaceutical sciences. 17th ed. Easton PN: Mack Publishing Company, 1985.
  1. US Pharmacist, Nov/Dec 80; Management of Potassium Disorders.
  1. Calcium Gluconate package insert, Aug. 1985.
  1. Calcium Glycerophosphate and Calcium Lactate package insert (Calphosan), 1990 PDR.
  1. Citracal package, July, 1985.
  1. Gilman AG, Rall TW, Nies AS, Taylor P, editors. Goodman and Gilman's the pharmacological basis of therapeutics. 8th ed. New York: Pergamon Press, 1990.
  1. Linder M, editor. Nutritional biochemistry and metabolism with clinical applications. New York: Elsevier, 1991: 146-7.
  1. O'Neil-Cutting MA, Crosby WH. The effect of antacids on the absorption of simultaneously ingested iron. JAMA 1986; 255: 1468-70.
  1. Kirschbaum B, Schoolwerth A. Acute aluminum toxicity associated with oral citrate and aluminum-containing antacids. Am J Med Sci 1989; 297(1): 9-11.
  1. Calcium Chloride Injection product information. (Upjohn–U.S.) Rev 12/85.
  1. Dawson Hughes B, Seligson F, Hughes V. Effects of calcium carbonate and hydroxyapatite on zinc and iron retention in postmenopausal women. Am J Clin Nutr 1986; 44: 83-8.
  1. Reviewer comment, 1987.
  1. Panelist comment, 1987.
  1. Reviewer comment, 1987.
  1. Reviewer comment, 1987.
  1. Reviewer comment, 1987.
  1. Panelists comment in response to Ciprofloxacin monograph, USP DI 89.
  1. Panelist comment, 1987.
  1. Manufacturer comment, 1987.
  1. Manufacturer comment, 1987.
  1. Manufacturer comment, 1987.
  1. Panelist comment, 1987.
  1. Panelist comment, 1987.
  1. Panelist comment, 1987.
  1. Manufacturer comment, 1987.
  1. Wilson JD, Braunwald E, Isselbacher KJ, Petersdorf RG, Martin JB, Fauci AS, Root RK, editors. Harrison's principles of internal medicine. 12th ed. New York: McGraw-Hill, Inc., 1991: 288.
  1. Panelist comment, 1987.
  1. Gilman AG, Goodman LS, Rall TW, Murad F, editors. Goodman and Gilman's the pharmocological basis of therapeutics. 7th ed. New York: Macmillan, 1985.
  1. Nestel A, Meyers A, Paiker J, et al. Effect of calcium supplement preparation containing small amounts of citrate on the absorption of aluminium in normal subjects and in renal failure patients. Nephron 1994; 68: 197-201.
  1. Bar-Or, D, Yoel G. Calcium and calciferolantagonise effect of verapamil in atrial fibrillation. Br Med J 1981; 282: 1585-6.
  1. Committee on Nutritional Status during Pregnancy, National Academy of Sciences. Washington DC: National Academy Press, 1990: 1-23.
  1. Panelist comment
  1. Reviewer comment, 1989.
  1. Panelist comment, 1989.
  1. Panelist comment, 1989.
  1. Panelist comment, 1989.
  1. Panelist comment, 1989.
  1. Manufacturer comment, 1989.
  1. Panelist comment, 1989.
  1. Reviewer comment, 1989.
  1. Panelist comment, 1989.
  1. Panelist comment, 1989.
  1. Communication from Sandy Boyer, USP DI staff—Change in Calcium Channel Blocking Agents (Systemic) monograph for DI 1990.
  1. Calcium chloride 10% product information (IMS—U.S.) Rec 11/14/88, Rev 6/85.
  1. Calcium gluceptate product information (Lilly—U.S.) Rec 1/89, Rev 3/88.
  1. Calcium gluconate product information (Upjohn—U.S.) Rev 8/85.
  1. Panelist comment, 1989.
  1. National Research Council. Recommended dietary allowances. 10th ed. Washington DC: National Academy Press, 1989.
  1. Frost R. Effect of Al hydroxide and calcium carbonate antacids on ciprofloxacin bioavailability. Clin Pharm Therap 1989; 45(2): 165.
  1. Polk R. Drug-drug interactions with ciprofloxacin and other fluoroquinolones. Am J Med 1989; 879 (suppl 5A): 76S-81S.
  1. Manufacturer comment, 1989.
  1. Sodium bicarbonate injection product information (Lypho Med—U.S.) Rec 3/89, Rev 1/87, U.S.
  1. Nilas M, Christiansen C, Rodbro P. Calcium supplementation and postmenopausal bone loss. Br Med J 1984; 289: 1103-6.
  1. Stevenson J, Whitehead M, Padwick M et al. Dietary intake of calcium and postmenopausal bone loss. Br Med J 1988; 297: 15-7.
  1. Panelist comment, 1991.
  1. Manufacturer comment, 1991.
  1. Ruis B, Thomsen K, Christiansen C. Does calcium supplementation prevent postmenopausal bone loss? NEJM 1987; 316(4): 173-7.
  1. Panel consensus, 1991.
  1. Forster J, Monchik J, Martin H. A comparative study of serum ultrafiltrable, ionized, and total calcium in the diagnosis of primary hyperparathyroidism in patients with intermittent or no elevation in total calcium. Surgery 1988; 104: 1137-42.
  1. Peoples J. The role of pH in altering serum ionized calcium concentration. Surgery 1988; 104: 370-4.
  1. Panel comment, 1991.
  1. Panel comment, 1991.
  1. Shangraw R. Factors affecting dissolution and absorption of calcium supplements. Maryland Pharmacist, 6/86: 21-3.
  1. Panel comment, 1991.
  1. Calcibind product information, Mission Pharmacal.
  1. Lake K, Brown D. New drug therapy for kidney stones, a review of cellulose sodium phosphate, acetohydroxamic acid, and potassium citrate. July/Aug 1985; 19: 530-9.
  1. Didronel tablets product information (Norwich Eaton—U.S.) Rec 6/88, Rev 4/89.
  1. Hansten PD, Horn JR. Drug interactions. 6th ed. Philadelphia: Lea & Febiger, 1989.
  1. Sumycin product information (Squibb—U.S.) Rec 3/89, Rev 1/87.
  1. Cipro product information (Miles—U.S.) Rec 4/89, Rev 1/89.
  1. Nix D et al. Inhibition of norfloxacin absorption by antacids. Antimicrob Agents Chem 1990; 34(3): 432-5.
  1. Gora M, Seth S, Nicks S et al. Milk-alkali syndrome associated with use of chlorothiazide and calcium carbonate. Clin Pharm 1989; 8: 227-9.
  1. Tatro DS, editor. Drug interaction facts. St Louis: Facts and Comparisons, 1990: 757.
  1. Drugs of choice, 1984-1985, p 701.
  1. Gugler R, Allayer A. Effects of antacids on the clinical pharmacokinetics of drugs. Clin Pharmacokin 1990; 18(3): 210-9.
  1. Quamme G. Renal handling of magnesium: drug and hormone interactions. Magnesium 1986; 5(5-6): 248-72.
  1. AHFS, 1990 Edition.
  1. Gramacol product information, CPS, 1990.
  1. Briancon D et al. J Bone Mineral Res, 1990, 5(suppl 1): S71-73.
  1. O'Dell B. Mineral interactions relevant to nutrient requirements. J Nutr 1989; 119(12 suppl): 1832-8.
  1. Jenkins J, Best T, Nicks S et al. Milk-alkali syndrome with a serum calcium level of 22 mg/dl and J waves on the ECG. South Med J 1987; 80(11): 1444-9.
  1. Cook J, Dassenko S, Whittaker P. Calcium supplementation: effect on iron absorption. Am J Clin Nutr 1991; 53: 106-11.
  1. Hallberg L, Brune M, Erlandsson M et al. Calcium: effect of different amounts on nonheme- and heme-iron absorption in humans. Am J Clin Nutr 1991; 53: 112-119.
  1. Sanchez-Ramos L, Briones D, Kaunitz A, et al. Prevention of pregnancy-induced hypertension by calcium supplementation in angiotensin II-sensitive patients. Obstet Gynecol 1994; 349-53.
  1. Panel consensus, 1990.
  1. Calcium-Sandoz product information, 1990 CPS.
  1. Calcium Stanley product information, 1990 CPS.
  1. Panelists comments, 1991.
  1. Panelist comment, 1991.
  1. Panel consensus, 1992.
  1. Calcium acetate product information (Abbott—US), Rev 1/91, Rec 4/95.
  1. Fleeger CA, editor. USP dictionary of USAN and international drug names 1995. Rockville, MD: The United States Pharmacopeial Convention, Inc., 1994: 114-5.
  1. Carter B, Garnett W, Pellock J, et al. Effect of antacids on phenytoin bioavailability. Ther Drug Monit 1981; 3(4): 333-40.
  1. Petroianu A, Barquete J, Plentz E, et al. Acute effects of alcohol ingestion on the human serum concentrations of calcium and magnesium. J Int Med Res 1991; 19: 410-3.
  1. Nutrition and Electrolytes Advisory Panel meeting, 1/95.
  1. Trissel LA. ASHP handbook on injectable drugs. 8th ed. Bethesda MD: American Society of Hospital Pharmacists, 1994: 138.
Hide
(web1)