Citric Acid, Sodium Citrate, and Potassium Citrate

Medically reviewed by Drugs.com. Last updated on Jun 19, 2023.

Pronunciation

(SIT rik AS id, SOW dee um SIT rate, & poe TASS ee um SIT rate)

Index Terms

• Polycitra
• Potassium Citrate, Citric Acid, and Sodium Citrate
• Sodium Citrate, Citric Acid, and Potassium Citrate

Dosage Forms

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

Solution, Oral:

Cytra-3: Citric acid 334 mg, sodium citrate 500 mg, and potassium citrate 550 mg per 5 mL (473 mL) [sugar free; contains fd&c yellow #6, polyethylene glycol, propylene glycol, sodium benzoate, sodium saccharin; raspberry flavor]

Virtrate-3: Citric acid 334 mg, sodium citrate 500 mg, and potassium citrate 550 mg per 5 mL (473 mL [DSC]) [sugar free; contains fd&c yellow #6 (sunset yellow), polyethylene glycol, propylene glycol, saccharin sodium, sodium benzoate; raspberry flavor]

Generic: Citric acid 334 mg, sodium citrate 500 mg, and potassium citrate 550 mg per 5 mL (473 mL)

Brand Names: U.S.

• Cytra-3
• Virtrate-3 [DSC]

Pharmacologic Category

• Alkalinizing Agent

Metabolism

≥95% via hepatic oxidation to bicarbonate

Excretion

Urine (<5% as unchanged drug)

Use: Labeled Indications

Conditions where long-term maintenance of an alkaline urine is desirable as in control and dissolution of uric acid and cystine calculi of the urinary tract

Contraindications

Severe renal impairment with oliguria or azotemia; untreated Addison’s disease; severe myocardial damage.

Dosing: Adult

Alkalinizing agent/bicarbonate precursor/potassium supplement: Oral: 15-30 mL diluted in water after meals and at bedtime

Dosing: Geriatric

Refer to adult dosing.

Dosing: Pediatric

Note: Consider the contribution of sodium and potassium when determining the appropriate bicarbonate replacement: 1 mL of oral solution contains 2 mEq of bicarbonate, 1 mEq of sodium, and 1 mEq of potassium. Individualize dose as determined by disease and patient-specific targets.

Renal tubular acidosis (RTA), distal (Type 1): Limited data available: Note: Dose requirements may vary with age. Infants, Children, and Adolescents: Oral: Usual dose: 2 to 4 mEq bicarbonate/kg/day (1 to 2 mL/kg/day) in divided doses; reported range: 1 to 7 mEq bicarbonate/kg/day; adjust dose to maintain target serum CO₂ (Chan 2001; Kliegman 2016; Rodríguez Soriano 2002; Santos 1986).

Renal tubular acidosis (RTA), proximal (Type 2): Limited data available: Note: Dose requirements may vary with age; for Type 2 RTA, bicarbonate doses are higher than those required for other types of RTA. Infants, Children, and Adolescents: Oral: Usual range: 10 to 20 mEq bicarbonate/kg/day (5 to 10 mL/kg/day) in divided doses (Chan 2001; Kliegman 2016; Rodríguez Soriano 2002); Note: May not be appropriate as monotherapy in some cases due to high therapeutic alkali requirement and corresponding potassium load; could be used in combination with sodium citrate formulations to meet alkali needs (Rodríguez Soriano 2002).

Systemic alkalinization; chronic:

Volume-based dosing: Children and Adolescents: Oral: 5 to 15 mL (10 to 30 mEq bicarbonate) per dose after meals and at bedtime

Weight-based dosing (mEq bicarbonate/kg): Limited data available: Infants, Children, and Adolescents: Oral: 2 to 3 mEq bicarbonate/kg/day (1 to 1.5 mL/kg/day) in 3 to 4 divided doses; adjust dose to targeted serum bicarbonate levels; typical adult doses do not exceed 60 mEq/dose (30 mL/dose) (Kliegman 2007)

Administration

Administer after meals. Dilute with water prior to administration. Chilling solution prior to dosing helps to enhance palatability. May follow dose with additional fluids.

Dietary Considerations

Should be taken after meals to avoid GI upset or laxative effect.

Storage

Store at controlled room temperature of 20°C to 25°C (68°F to 77°F); do not freeze. Protect from excessive heat.

Drug Interactions

Aliskiren: Potassium Salts may enhance the hyperkalemic effect of Aliskiren. Monitor therapy

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

Aluminum Hydroxide: Citric Acid Derivatives may increase the absorption of Aluminum Hydroxide. Monitor therapy

Amantadine: Alkalinizing Agents may increase the serum concentration of Amantadine. 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. Consider therapy modification

Angiotensin II Receptor Blockers: Potassium Salts may enhance the hyperkalemic effect of Angiotensin II Receptor Blockers. Monitor therapy

Angiotensin-Converting Enzyme Inhibitors: Potassium Salts may enhance the hyperkalemic effect of Angiotensin-Converting Enzyme Inhibitors. Monitor therapy

Anticholinergic Agents: May enhance the ulcerogenic effect of Potassium Citrate. Avoid combination

Drospirenone: Potassium Salts may enhance the hyperkalemic effect of Drospirenone. Monitor therapy

Eplerenone: May enhance the hyperkalemic effect of Potassium Salts. Management: This combination is contraindicated in patients receiving eplerenone for treatment of hypertension. Potassium supplements may be needed to treat/prevent hypokalemia in selected patients with heart failure receiving eplerenone and high dose loop diuretics. Consider therapy modification

Heparin: May enhance the hyperkalemic effect of Potassium Salts. Monitor therapy

Heparins (Low Molecular Weight): May enhance the hyperkalemic effect of Potassium Salts. Monitor therapy

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

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

Nicorandil: May enhance the hyperkalemic effect of Potassium Salts. Monitor therapy

Potassium-Sparing Diuretics: Potassium Salts may enhance the hyperkalemic effect of Potassium-Sparing Diuretics. Management: Avoid coadministration of a potassium-sparing diuretic and a potassium salt. This combination should only be used in cases of significant hypokalemia, and only if serum potassium can be closely monitored. Consider therapy modification

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

Adverse Reactions

The following adverse drug reactions and incidences are derived from product labeling unless otherwise specified. Frequency not defined.

Cardiovascular: Cardiac abnormalities

Endocrine & metabolic: Metabolic alkalosis, calcium levels, hyperkalemia, hypernatremia

Gastrointestinal: Diarrhea

Neuromuscular & skeletal: Tetany

Warnings/Precautions

Disease-related concerns:

• Cardiovascular disease: Use with caution in patients with heart failure or hypertension; contains sodium.

• Edema: Use with caution in patients with peripheral or pulmonary edema; contains sodium.

• Hepatic impairment: Citrate is converted to bicarbonate in the liver; this conversion may be blocked in patients in hepatic failure.

• Renal impairment: Use with caution in patients with renal impairment; contains sodium. Contraindicated in patients with severe impairment.

• Severely ill: Use with caution in patients who are severely ill; conversion to bicarbonate may be impaired.

• Shock: Use with caution in patients who are in shock; conversion to bicarbonate may be impaired.

Concurrent drug therapy issues:

• Digitalis: Use with caution in digitalized patients; may be more susceptible to potentially life-threatening cardiac effects with rapid changes in serum potassium concentrations.

• Potassium-altering therapies: Use with caution in patients receiving concomitant medications or therapies that increase potassium (eg, ACEI, potassium-sparing diuretics, potassium containing salt substitutes).

Dosage form specific issues:

• Benzyl alcohol and derivatives: Some dosage forms may contain sodium benzoate/benzoic acid; benzoic acid (benzoate) is a metabolite of benzyl alcohol; large amounts of benzyl alcohol (≥99 mg/kg/day) have been associated with a potentially fatal toxicity (“gasping syndrome”) in neonates; the “gasping syndrome” consists of metabolic acidosis, respiratory distress, gasping respirations, CNS dysfunction (including convulsions, intracranial hemorrhage), hypotension, and cardiovascular collapse (AAP ["Inactive" 1997]; CDC, 1982); some data suggests that benzoate displaces bilirubin from protein binding sites (Ahlfors, 2001); avoid or use dosage forms containing benzyl alcohol derivative with caution in neonates. See manufacturer’s labeling.

• Propylene glycol: Some dosage forms may contain propylene glycol; large amounts are potentially toxic and have been associated hyperosmolality, lactic acidosis, seizures, and respiratory depression; use caution (AAP ["Inactive" 1997]; Zar, 2007).

Monitoring Parameters

Serum potassium, sodium, and bicarbonate; urinary pH

Patient Education

What is this drug used for?

• It is used to lower acid levels in the urine.

• It is used to prevent gout attacks.

WARNING/CAUTION: Even though it may be rare, some people may have very bad and sometimes deadly side effects when taking a drug. Tell your doctor or get medical help right away if you have any of the following signs or symptoms that may be related to a very bad side effect:

• High potassium like abnormal heartbeat, confusion, dizziness, passing out, weakness, shortness of breath, or numbness or tingling feeling

• Signs of an allergic reaction, like rash; hives; itching; red, swollen, blistered, or peeling skin with or without fever; wheezing; tightness in the chest or throat; trouble breathing, swallowing, or talking; unusual hoarseness; or swelling of the mouth, face, lips, tongue, or throat.

Note: This is not a comprehensive list of all side effects. Talk to your doctor if you have questions.

Consumer Information Use and Disclaimer: This information should not be used to decide whether or not to take this medicine or any other medicine. Only the healthcare provider has the knowledge and training to decide which medicines are right for a specific patient. This information does not endorse any medicine as safe, effective, or approved for treating any patient or health condition. This is only a limited summary of general information about the medicine's uses from the patient education leaflet and is not intended to be comprehensive. This limited summary does NOT include all information available about the possible uses, directions, warnings, precautions, interactions, adverse effects, or risks that may apply to this medicine. This information is not intended to provide medical advice, diagnosis or treatment and does not replace information you receive from the healthcare provider. For a more detailed summary of information about the risks and benefits of using this medicine, please speak with your healthcare provider and review the entire patient education leaflet.

Further information

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