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Citric Acid, Sodium Citrate, and Potassium Citrate

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:

Virtrate-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 (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)

Syrup, Oral:

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

Brand Names: U.S.

  • Cytra-3 [DSC]
  • Virtrate-3

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

Alkalinizing agent/bicarbonate precursor/potassium supplement: Oral: Children: 5-15 mL diluted in water after meals and at bedtime

Administration

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

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

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

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

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

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

Eplerenone: May enhance the hyperkalemic effect of Potassium Salts. Management: This combination is contraindicated in patients receiving eplerenone for treatment of hypertension. Consider therapy modification

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

Heparin (Low Molecular Weight): May enhance the hyperkalemic effect of Potassium Salts. 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. Consider therapy modification

Adverse Reactions

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

Pregnancy Risk Factor

Not established

Pregnancy Considerations

Use caution with toxemia of pregnancy.

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 signs of high potassium (abnormal heartbeat, confusion, dizziness, passing out, weakness, shortness of breath, or numbness or tingling feeling); severe nausea; severe vomiting; abdominal edema; severe abdominal pain; black, tarry, or bloody stools; or vomiting blood (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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