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Sodium Bicarbonate

Pronunciation

Pronunciation

(SOW dee um bye KAR bun ate)

Index Terms

  • Baking Soda
  • NaHCO3
  • Sodium Acid Carbonate
  • Sodium Hydrogen Carbonate

Dosage Forms

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

Powder, Does not apply:

Generic: (1 g, 100 g, 454 g [DSC], 500 g, 2270 g [DSC], 2500 g, 10000 g, 12000 g [DSC])

Powder, Oral:

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

Solution, Intravenous:

Neut: 4% (5 mL)

Generic: 4.2% (5 mL, 10 mL); 7.5% (50 mL); 8.4% (10 mL, 50 mL)

Tablet, Oral:

Generic: 325 mg, 650 mg

Brand Names: U.S.

  • Neut

Pharmacologic Category

  • Alkalinizing Agent
  • Antacid
  • Electrolyte Supplement, Oral
  • Electrolyte Supplement, Parenteral

Pharmacology

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

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

Absorption

Oral: Well absorbed

Excretion

Urine (<1%)

Onset of Action

Oral: 15 minutes; IV: Rapid

Duration of Action

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

Use: Labeled Indications

Management of metabolic acidosis; gastric hyperacidity; as an alkalinization agent for the urine; treatment of hyperkalemia; management of overdose of certain drugs, including tricyclic antidepressants and aspirin

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

Use: Unlabeled

Prevention of contrast-induced nephropathy (CIN)

Contraindications

Alkalosis, hypernatremia, severe pulmonary edema, hypocalcemia, unknown abdominal pain

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

Dosing: Adult

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

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

Metabolic acidosis: IV: Dosage should be based on the following formula if blood gases and pH measurements are available:

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

Administer 1/2 dose initially, then remaining 1/2 dose over the next 24 hours; monitor pH, serum HCO3-, and clinical status. Note: These equations provide an estimated replacement dose. The underlying cause and degree of acidosis may result in the need for larger or smaller replacement doses. In most cases, the initial goal of therapy is to target a pH of ~7.2 and a plasma bicarbonate level of ~10 mEq/L to prevent overalkalinization.

Note: If acid-base status is not available: 2-5 mEq/kg IV infusion over 4-8 hours; subsequent doses should be based on patient's acid-base status

Hyperkalemia (ACLS, 2010): IV: 50 mEq over 5 minutes (as appropriate, consider methods of enhancing potassium removal/excretion)

Chronic renal failure: Oral: Initiate when plasma HCO3- <15 mEq/L Start with 20-36 mEq/day in divided doses, titrate to bicarbonate level of 18-20 mEq/L

Renal tubular acidosis: Oral:

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

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

Urine alkalinization: Oral: Initial: 48 mEq (4 g), then 12-24 mEq (1-2 g) every 4 hours; dose should be titrated to desired urinary pH; doses up to 16 g/day (200 mEq) in patients <60 years and 8 g (100 mEq) in patients >60 years

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

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

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

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

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

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

Prevention of contrast-induced nephropathy (off-label use): IV infusion: 154 mEq/L sodium bicarbonate in D5W solution: 3 mL/kg/hour for 1 hour immediately before contrast injection, then 1mL/kg/hour during contrast exposure and for 6 hours after procedure

To prepare solution, remove 154 mL from 1000 mL bag of D5W; replace with 154 mL of 8.4% sodium bicarbonate; resultant concentration is 154 mEq/L (Merten, 2004); more practically, institutions may remove 150 mL from 1000 mL bag of D5W and replace with 150 mL of 8.4% sodium bicarbonate; resultant concentration is 150 mEq/L

Dosing: Geriatric

Refer to adult dosing.

Dosing: Pediatric

Cardiac arrest (PALS, 2010): IV, I.O.: Infants and Children: 1 mEq/kg/dose; repeat doses should be guided by arterial blood gases; children <2 years of age should receive 4.2% (0.5 mEq/mL) solution. Note: If I.O. route is used for administration and is subsequently used to obtain blood samples for acid-base analysis, results will be inaccurate.

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

Metabolic acidosis: IV: Infants and Children: Dosage should be based on the following formula if blood gases and pH measurements are available:

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

Administer 1/2 dose initially, then remaining 1/2 dose over the next 24 hours; monitor pH, serum HCO3-, and clinical status. Note: These equations provide an estimated replacement dose. The underlying cause and degree of acidosis may result in the need for larger or smaller replacement doses. In most cases, the initial goal of therapy is to target a pH of ~7.2 and a plasma bicarbonate level of ~10 mEq/L to prevent overalkalinization.

Note: If acid-base status is not available: Dose for older Children: 2-5 mEq/kg IV infusion over 4-8 hours; subsequent doses should be based on patient's acid-base status.

Chronic renal failure: Oral: Children: Initiate when plasma HCO3- <15 mEq/L: 1-3 mEq/kg/day

Renal tubular acidosis, distal: Oral: Children: 2-3 mEq/kg/day

Renal tubular acidosis, proximal: Children: Initial: 5-10 mEq/kg/day; maintenance: Increase as required to maintain serum bicarbonate in the normal range

Neutralize lidocaine with epinephrine dental anesthetic: Children and Adolescents: Neutralizing additive: Refer to adult dosing.

Urine alkalinization: Oral: Children: 1-10 mEq (84-840 mg)/kg/day in divided doses every 4-6 hours; dose should be titrated to desired urinary pH.

Reconstitution

Prevention of contrast-induced nephropathy (off-label use): Remove 154 mL from 1000 mL bag of D5W; replace with 154 mL of 8.4% sodium bicarbonate; resultant concentration is 154 mEq/L (Merten, 2004); more practically, institutions may remove 150 mL from 1000 mL bag of D5W and replace with 150 mL of 8.4% sodium bicarbonate; resultant concentration is 150 mEq/L

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

Administration

For IV administration to infants, use the 0.5 mEq/mL solution or dilute the 1 mEq/mL solution 1:1 with sterile water; for direct IV infusion in emergencies, administer slowly (maximum rate in infants: 10 mEq/minute); for infusion, dilute to a maximum concentration of 0.5 mEq/mL in dextrose solution and infuse over 2 hours (maximum rate of administration: 1 mEq/kg/hour).

Vesicant (at concentrations ≥8.4%); ensure proper needle or catheter placement prior to and during IV infusion. Avoid extravasation.

Extravasation management: If extravasation occurs, stop infusion immediately and disconnect (leave needle/cannula in place); gently aspirate extravasated solution (do NOT flush the line); initiate hyaluronidase antidote; remove needle/cannula; apply dry cold compresses (Hurst, 2004); elevate extremity.

Hyaluronidase: SubQ: Inject four to five separate 0.2 mL injections of 15 units/mL around area of extravasation (Hurst, 2004).

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

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

Dietary Considerations

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

Compatibility

Stable in D51/4NS, D51/2NS, D5NS, D5W, D10W, 1/2NS, NS; incompatible with acids, acidic salts, alkaloid salts, calcium salts, catecholamines, and atropine.

Y-site administration: Incompatible with allopurinol, amiodarone, amphotericin B cholesteryl sulfate complex, anidulafungin, calcium chloride, doxorubicin liposome, fenoldopam, hetastarch in lactate electrolyte injection (Hextend®), idarubicin, imipenem/cilastatin, inamrinone, leucovorin calcium, midazolam, nalbuphine, ondansetron, oxacillin, sargramostim, verapamil, vincristine, vinorelbine.

Compatibility in syringe: Incompatible with dimenhydrinate, glycopyrrolate, mepivacaine, metoclopramide, pantoprazole, thiopental.

Storage

Store injection at room temperature. Protect from heat and from freezing. Use only clear solutions.

Neutralizing additive (dental use): Store at 20°C to 25°C (68°F to 77°F).

Drug Interactions

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

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

Amphetamines: Alkalinizing Agents may decrease the excretion of Amphetamines. Consider therapy modification

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

Atazanavir: Antacids may decrease the absorption of Atazanavir. Consider therapy modification

Bisacodyl: Antacids may diminish the therapeutic effect of Bisacodyl. Antacids may cause the delayed-release bisacodyl tablets to release drug prior to reaching the large intestine. Gastric irritation and/or cramps may occur. Consider therapy modification

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

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

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

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

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

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

Cefuroxime: Antacids may decrease the serum concentration of Cefuroxime. Management: Consider administering antacids and cefuroxime at least 2 hours apart. Consider therapy modification

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

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

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

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

Dabrafenib: Antacids may decrease the serum concentration of Dabrafenib. Monitor therapy

Dasatinib: Antacids may decrease the absorption of Dasatinib. Consider therapy modification

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

Dexmethylphenidate: Antacids may increase the absorption of Dexmethylphenidate. Specifically, antacids may interfere with the normal release of drug from the extended-release capsules (Focalin XR brand), which could result in both increased absorption (early) and decreased delayed absorption. Monitor therapy

Elvitegravir: Antacids may decrease the serum concentration of Elvitegravir. Management: Separate administration of antacids and elvitegravir-containing products by at least 2 hours in order to minimize the risk for an interaction. Consider therapy modification

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

Flecainide: Sodium Bicarbonate may diminish the arrhythmogenic effect of Flecainide. Sodium Bicarbonate may increase the serum concentration of Flecainide. Monitor therapy

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

Gabapentin: Antacids may decrease the serum concentration of Gabapentin. Management: Administer gabapentin at least 2 hours after antacid administration. Monitor patients closely for evidence of reduced response to gabapentin therapy when both of these drugs are being used. Consider therapy modification

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

HMG-CoA Reductase Inhibitors: Antacids may decrease the serum concentration of HMG-CoA Reductase Inhibitors. Monitor therapy

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

Iron Salts: Antacids may decrease the absorption of Iron Salts. Exceptions: Ferric Carboxymaltose; Ferric Citrate; Ferric Gluconate; Ferric Pyrophosphate Citrate; Ferumoxytol; Iron Dextran Complex; Iron Sucrose. Consider therapy modification

Isoniazid: Antacids may decrease the absorption of Isoniazid. Consider therapy modification

Itraconazole: Antacids may decrease the serum concentration of Itraconazole. Management: Administer itraconazole at least 1 hour after and 2 hours before administration of any antacids. Itraconazole oral suspension may be less sensitive to the effects of decreased gastric acidity. Consider therapy modification

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

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

Lithium: Sodium Bicarbonate may increase the excretion of Lithium. 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

Mesalamine: Antacids may diminish the therapeutic effect of Mesalamine. Antacid-mediated increases in gastrointestinal pH may cause the premature release of mesalamine from specific sustained-release mesalamine products. Management: Avoid concurrent administration of antacids with sustained-release mesalamine products. Separating antacid and mesalamine administration, and/or using lower antacid doses may be adequate means of avoiding this interaction. Consider therapy modification

Methenamine: Antacids may diminish the therapeutic effect of Methenamine. Consider therapy modification

Methylphenidate: Antacids may increase the absorption of Methylphenidate. Specifically, antacids may interfere with the normal release of drug from the extended-release capsules (Ritalin LA brand), which could result in both increased absorption (early) and decreased delayed absorption. Monitor therapy

Multivitamins/Minerals (with ADEK, Folate, Iron): Antacids may decrease the serum concentration of Multivitamins/Minerals (with ADEK, Folate, Iron). Specifically, antacids may decrease the absorption of orally administered iron. Management: Separate dosing of oral iron-containing multivitamin preparations and antacids by as much time as possible in order to minimize impact on therapeutic efficacy of the iron preparation. Consider therapy modification

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

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

PenicillAMINE: Antacids may decrease the serum concentration of PenicillAMINE. Consider therapy modification

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

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

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

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

Rilpivirine: Antacids may decrease the serum concentration of Rilpivirine. Management: Administer antacids at least 2 hours before or 4 hours after rilpivirine. Consider therapy modification

Riociguat: Antacids may decrease the serum concentration of Riociguat. Management: Separate the administration of antacids and riociguat by at least 1 hour in order to minimize any potential interaction. Consider therapy modification

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

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

Tetracycline Derivatives: Antacids may decrease the absorption of Tetracycline Derivatives. Consider therapy modification

Trientine: Antacids may decrease the absorption of Trientine. Management: Separate trientine dosing from other oral drugs (eg, antacids) by at least 1 hour. Monitor for decreased therapeutic effects of trientine if an antacid is initiated/dose increased, or increased effects if an antacid is discontinued/dose decreased. Consider therapy modification

Adverse Reactions

Frequency not defined.

Cardiovascular: Cerebral hemorrhage, CHF (aggravated), edema

Central nervous system: Tetany

Gastrointestinal: Belching, flatulence (with oral), gastric distension

Endocrine & metabolic: Hypernatremia, hyperosmolality, hypocalcemia, hypokalemia, increased affinity of hemoglobin for oxygen-reduced pH in myocardial tissue necrosis when extravasated, intracranial acidosis, metabolic alkalosis, milk-alkali syndrome (especially with renal dysfunction)

Respiratory: Pulmonary edema

Warnings/Precautions

Concerns related to adverse effects:

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

Disease-related concerns:

• Cirrhosis: Use with caution in patients with cirrhosis.

• Edema: Use with caution in patients with edema.

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

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

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

Special populations:

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

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

Dosage form specific issues:

• Injection: Use of IV NaHCO3 should be reserved for documented metabolic acidosis and for hyperkalemia-induced cardiac arrest. Routine use in cardiac arrest is not recommended.

Pregnancy Risk Factor

C

Pregnancy Considerations

Animal reproduction studies have not been conducted. The use of sodium bicarbonate in pregnant women for the management of cardiac arrest and metabolic acidosis is the same as in nonpregnant women (Campbell, 2009; Vanden Hoek, 2010). Antacids containing sodium bicarbonate should not be used during pregnancy due to their potential to cause metabolic alkalosis and fluid overload (Mahadevan, 2007).

Patient Education

• Discuss specific use of drug and side effects with patient as it relates to treatment. (HCAHPS: During this hospital stay, were you given any medicine that you had not taken before? Before giving you any new medicine, how often did hospital staff tell you what the medicine was for? How often did hospital staff describe possible side effects in a way you could understand?)

• Have patient report immediately to prescriber severe dyspepsia, fasciculations, muscle rigidity, muscle spasms, edema of extremities, or injection site pain or irritation (HCAHPS).

• Educate patient about signs of a significant reaction (eg, wheezing; chest tightness; fever; itching; bad cough; blue skin color; seizures; or swelling of face, lips, tongue, or throat). Note: This is not a comprehensive list of all side effects. Patient should consult prescriber for additional questions.

Intended Use and Disclaimer: Should not be printed and given to patients. This information is intended to serve as a concise initial reference for healthcare professionals to use when discussing medications with a patient. You must ultimately rely on your own discretion, experience and judgment in diagnosing, treating and advising patients.

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