Calcium Salts

Drug class: Antineoplastic Agents

Usage of Calcium Salts

Dietary Requirements (oral therapy)

For maintaining an adequate intake of calcium to support the development and preservation of bone mass at a level sufficient to prevent fractures associated with osteopenia or osteoporosis in later life and of other calcified tissues (e.g., teeth).

Life long intake of adequate calcium is necessary for good bone health at any age; calcium requirements may increase among older individuals.

Adequate intakes of calcium can be accomplished through changes in food consumption behaviors, consumption of nutrient-fortified foodstuffs, use of dietary supplements, or a combination of these.

In the US and Canada, calcium principally is obtained from dairy products. Other principal sources include fruits, vegetables, and grain products. In addition, many healthy individuals take dietary supplements containing calcium.

For specific information on currently recommended Dietary Reference Intakes (DRIs) of calcium for various life-stage and gender groups, see Dosage under Dosage and Administration.

Hypocalcemia (parenteral and oral therapy)

Calcium salts are used as a source of calcium cation for the treatment or prevention of calcium depletion when dietary measures are inadequate. Conditions associated with calcium deficiency include hypoparathyroidism, achlorhydria, chronic diarrhea, vitamin D deficiency, steatorrhea, sprue, pregnancy and lactation, menopause, pancreatitis, renal failure, alkalosis, and hyperphosphatemia.

Some clinicians consider IV calcium chloride the calcium salt of choice to prevent hypocalcemia during transfusions with citrated blood. In addition to being irritating, however, the chloride salt is acidifying and generally should not be used when acidosis coincides with hypocalcemia (e.g., renal failure).

The calcium glycerophosphate and Calcium lactate fixed-combination injection is used IM to increase serum calcium concentrations.

Administration of certain drugs (e.g., some diuretics, anticonvulsants) may sometimes result in hypocalcemia, which may warrant calcium replacement therapy.

Calcium is administered in long-term electrolyte replacement regimens.

Use of calcium salts should not preclude the use of other measures intended to correct the underlying cause of calcium depletion.

Vitamin D analogs may be administered concomitantly with oral calcium salts for the treatment of chronic hypocalcemia, especially when caused by vitamin D deficiency.

Calcium salts may be used orally for the treatment of hypocalcemia secondary to the administration of anticonvulsant drugs.

Hypocalcemic Tetany (IV therapy)

IV Calcium Gluconate is considered the salt of choice for the treatment of acute hypocalcemia.

Calcium salts are used to treat acute hypocalcemic tetany secondary to renal failure, hypoparathyroidism, premature delivery, and/or maternal diabetes mellitus in infants, and poisoning with magnesium, oxalic acid, radiophosphorus, carbon tetrachloride, fluoride, phosphate, strontium, or radium.

Hypoparathyroidism, Chronic (oral therapy)

Calcium salts may be used for treatment of chronic hypoparathyroidism.

Latent Tetany (oral therapy)

Calcium salts may be used for the treatment of latent tetany.

Osteoporosis (oral therapy)

Calcium salts (e.g., Calcium carbonate, Calcium citrate) are used as supplements in the prevention and treatment of osteoporosis when dietary intake of calcium is insufficient.

Adequate intake of calcium and vitamin D (which increases absorption of calcium) is universally recommended for all individuals to diminish age-related bone loss and prevent osteoporosis.

In addition to lifestyle modifications (e.g., regular weight-bearing exercise, avoidance of excessive alcohol and tobacco use), the National Osteoporosis Foundation recommends a daily calcium intake of 1 g in men 50–70 years of age, and 1.2 g in women ≥51 years of age and men ≥71 years of age.

The combination of calcium and vitamin D has been shown to reduce risk of fractures.

Glucocorticoid-induced Osteoporosis (oral therapy)

Calcium salts are used for prevention of glucocorticoid-induced osteoporosis.

The American College of Rheumatology (ACR) recommends optimizing dietary intake of calcium (1–1.2 g daily) and vitamin D (600–800 units daily) in all patients receiving long-term glucocorticoid therapy (defined as a daily dosage equivalent to 2.5 mg of prednisone or greater for ≥3 months).

Because of concerns about potential harms (e.g., cardiovascular risks), ACR states that additional study is needed to determine potential benefits versus risks of calcium and vitamin D supplementation in patients receiving glucocorticoids.

Osteomalacia (oral therapy)

Calcium salts may be used for treatment of osteomalacia.

Anticonvulsant-induced Hypocalcemia (oral therapy)

Calcium salts may be used for treatment of rickets, latent tetany, and hypocalcemia secondary to the administration of anticonvulsant drugs.

Rickets (oral therapy)

Calcium salts may be used for treatment of rickets.

Hyperphosphatemia in Chronic Renal Failure (oral therapy)

Calcium acetate and calcium carbonate are considered the salts of choice for chronic renal failure.

In addition to providing a source of calcium, calcium acetate or carbonate sequesters phosphate in the intestine by forming insoluble phosphates that are excreted fecally, thus reducing serum phosphate concentrations and secondary hyperparathyroidism.

Calcium carbonate partially corrects metabolic acidosis which may occur in chronic renal failure.

Because of the risk of aluminum accumulation and resultant neurotoxic and osteomalacic effects, most clinicians no longer use aluminum hydroxide to inhibit phosphorus absorption; instead calcium acetate or carbonate and/or non-calcium-, non-aluminum-, non-magnesium-containing phosphate binders (e.g., lanthanum carbonate, Sevelamer hydrochloride) currently are used.

When taken with meals, calcium acetate or carbonate can contribute to controlling hyperphosphatemia in chronic renal failure by binding to and inhibiting absorption of phosphates in the GI tract.

Exercise caution in patients undergoing chronic hemodialysis to prevent hypophosphatemia.

Patients with end-stage renal failure may develop hypercalcemia when calcium is administered with meals; do not give calcium supplementation concomitantly when calcium salts are used to control hyperphosphatemia in such patients.

Progressive hypercalcemia secondary to overdose of calcium salts can occur and may require emergency treatment measures.

Chronic hypercalcemia also may lead to vascular and other soft-tissue calcification; periodic (e.g., twice weekly) monitoring of calcium concentrations is recommended during the initial dose adjustment. One manufacturer recommends that the serum calcium times phosphate (Ca × P) product should not exceed 66. Radiographic evaluation of a suspected anatomical region for early soft-tissue calcification may be useful.

Advanced Cardiovascular Life Support (IV therapy)

Because of the lack of demonstrated benefit and potential for detrimental effects, calcium should not be used routinely during cardiac arrest unless there is documented hypocalcemia, calcium-channel blocker toxicity, hypermagnesemia, or hyperkalemia. When used in this setting, either calcium chloride or calcium gluconate may be administered.

Aminoglycoside Neuromuscular Blockade (IV therapy)

Calcium salts are used to antagonize neuromuscular blockade† [off-label] resulting from the use of aminoglycoside antibiotics (e.g., Gentamicin, kanamycin, Neomycin) with or without agents possessing neuromuscular blocking properties (e.g., gallamine triethiodide).

Magnesium Intoxication (IV therapy)

Calcium gluconate may be used in the treatment of magnesium sulfate overdosage.

Myasthenia Gravis (oral therapy)

Calcium salts are used as adjunctive treatment of myasthenia gravis.

In general, any oral calcium salt may be used for chronic replacement therapy.

Medullary Thyroid Carcinoma (IV therapy)

Calcium infusions (“calcium challenge”) are used in medullary thyroid carcinoma† [off-label].

Acid Indigestion (oral therapy)

Calcium carbonate or phosphate may be used for self-medication for the relief of acid indigestion, heartburn, and sour stomach.

Colic, Renal, Biliary, Intestinal, or Lead (IV and IM therapy)

Calcium salts have been used IM or IV as adjunctive therapy to reduce spasms in renal, biliary, intestinal, or lead colic.

Zollinger-Ellison Syndrome, Diagnosis (IV therapy)

Calcium infusions (“calcium challenge”) are used to diagnose the Zollinger-Ellison syndrome† [off-label].

Eaton-Lambert Syndrome (oral therapy)

Calcium salts are used as adjunctive treatment of the Eaton-Lambert syndrome.

In general, any oral calcium salt may be used for chronic replacement therapy.

Insect Bites and Other Sensitivity Reactions (IV therapy)

Calcium salts have been used IV as adjuncts to relieve muscle cramps in the treatment of insect bites or stings (e.g., black widow spider) or to decrease capillary permeability in sensitivity reactions characterized by urticaria or angioedema and in allergic conditions, including nonthrombocytopenic purpura, dermatitis herpetiformis, drug-induced pruritus, hay fever, and asthma.

Preeclampsia (oral therapy)

Although some evidence suggested a beneficial effect of calcium supplementation on preeclampsia, a large, well-designed study did not cOnfirm a beneficial effect of calcium supplementation in preventing preeclampsia during pregnancy. However, these findings do not obviate adequate dietary calcium intake during pregnancy nor do they address whether adequate or increased calcium intake can affect blood pressure favorably in pregnant women.

β-Adrenergic or Calcium-channel Blocking Agent Overdosage (IV therapy)

Some experts state that calcium salts may be considered in the treatment of calcium-channel blocking agent-induced toxicity.

Also may be useful in the treatment of β-adrenergic blocking agent toxicity in patients with shock refractory to other treatment measures.

Diuresis (oral therapy)

Calcium chloride, an acid-forming salt, has been used to promote diuresis, however, because it is irritating and loses effectiveness after a few days, it is rarely used for this effect.

Relate drugs

How to use Calcium Salts

Administration

Administer calcium orally (as acetate, carbonate, citrate, gluconate, lactate, or phosphate salt) or IV (as chloride or gluconate salt).

The fixed combination of calcium glycerophosphate and calcium lactate is injected IM.

Calcium chloride also may be administered by intraosseous (IO) injection† [off-label] during pediatric resuscitation; onset of action and systemic concentrations are comparable to those achieved with venous administration.

Oral Administration

Administer acetate, carbonate, citrate, gluconate, lactate, and phosphate salts of calcium orally.

Administer most oral calcium supplements 1–1.5 hours after meals or with a demulcent (e.g., milk). However, calcium carbonate powder generally should be administered with meals, since mixing the powder with food for administration is recommended.

Calcium salts used to bind dietary phosphate in patients with end-stage renal disease should be administered with meals (e.g., 10–15 minutes before, or during, the meal).

IV Administration

For solution and drug compatibility information, see Compatibility under Stability.

Calcium chloride or gluconate may be administered IV.

Calcium gluconate usually is administered IV as a 10% solution and calcium chloride as a 2–10% solution.

When injected IV, administer calcium salts slowly through a small needle into a large vein to avoid too rapid an increase in serum calcium and extravasation of calcium solution into the surrounding tissue with resultant necrosis.

Following IV injections, the patient should remain recumbent for a short time.

Close monitoring of serum calcium concentrations is essential during IV administration of calcium.

Children: Calcium salts should not be administered through scalp veins; oral administration of calcium supplements or calcium-rich foods should replace IV calcium therapy as soon as possible.

Dilution

Usually, administer IV undiluted.

Parenteral calcium salts also may be administered in a compatible large-volume IV infusion fluid. (See Solution Compatibility under Compatibility.)

Pharmacy bulk packages are for preparing IV admixtures only.

Rate of Administration

Administer IV calcium injections slowly at a rate not exceeding 0.7–1.8 mEq/minute.

Stop the injection if the patient complains of discomfort.

Pharmacy bulk packages must not be infused IV directly.

Administer pediatric dose for CPR by slow IV injection over 10–20 seconds.

IM or Sub-Q Injection

Calcium chloride should not be injected IM or into suBCUTAneous or perivascular tissue, since severe necrosis and sloughing may occur.

Although other calcium salts may cause mild to severe local reactions, they generally are less irritating than calcium chloride. (See Cautions.)

Although some manufacturers previously stated that calcium gluconate could be injected IM when IV administration was not possible, manufacturers of calcium gluconate currently state that the drug should not be injected IM or into subcutaneous tissue because of the potential for severe local reactions.

The fixed-combination of calcium glycerophosphate and calcium lactate is injected IM.

Dosage

Dosage of the oral calcium supplements usually is expressed in g or mg of elemental calcium and Depends on the requirements of the individual patient.

Dosage of parenteral calcium replacements usually is expressed as mEq of calcium and depends on individual patient requirements.

One mEq of elemental calcium is equivalent to 20 mg.

The calcium content of the various calcium salts is approximately:

Calcium Salt

Calcium Content

calcium acetate

253 mg (12.7 mEq) per g

calcium carbonate

400 mg (20 mEq) per g

calcium chloride

270 mg (13.5 mEq) per g

calcium citrate

211 mg (10.6 mEq) per g

calcium gluceptate

82 mg (4.1 mEq) per g

calcium gluconate

90 mg (4.5 mEq) per g

calcium glycerophosphate

191 mg (9.6 mEq) per g

calcium lactate

130 mg (6.5 mEq) per g

calcium phosphate dibasic anhydrous

290 mg (14.5 mEq) per g

calcium phosphate dibasic dihydrate

230 mg (11.5 mEq) per g

calcium phosphate tribasic

400 mg (20 mEq) per g

Oral calcium supplements usually are administered in 3 or 4 divided doses daily.

Optimum calcium absorption may require supplemental vitamin D in individuals with inadequate vitamin D intake, those with impaired renal activation of the vitamin, or those not receiving adequate exposure to sunlight.

Pediatric Patients

Dietary Requirements Oral

Dietary reference intake values for elemental calcium currently recommended by the National Academy of Sciences (NAS) in healthy children are as follows. Adequate intakes (AIs) are given for infants <1 year of age because of inadequate data to establish recommended daily allowances (RDAs) in this age group.

Infants <6 Months of Age:

AI of 200 mg daily (presumed to be met by human milk).

Infants 6–12 Months of Age:

AI of 260 mg daily (taking into account additional intake of calcium from food).

Children 1–3 Years of Age:

RDA of 700 mg daily.

Children 4–8 Years of Age:

RDA of 1 g daily.

Children 9–18 Years of Age:

RDA of 1.3 g daily.

Hypocalcemia

Calcium gluconate usually is administered IV as a 10% solution and calcium chloride as a 2–10% solution.

Calcium replacement requirements can be estimated by clinical condition and/or serum calcium determinations.

Prevention Oral

Neonates: Usually, 50–150 mg/kg of elemental calcium daily; do not exceed 1 g daily.

Children: Usually, 45–65 mg/kg of elemental calcium daily.

Treatment When Prompt Elevation of Serum Calcium Is Required IV

Infants: <0.93 mEq of calcium; may be repeated every 1–3 days depending on the patient’s response.

Children: Usually, initial dose of 0.93–2.3 mEq of calcium; may be repeated every 1–3 days depending on the patient’s response.

Alternatively, one manufacturer recommends a pediatric IV calcium dose of 0.272 mEq/kg, up to a maximum total daily dosage of 1.36–13.6 mEq, in the treatment of hypocalcemic disorders.

Hypocalcemic Tetany IV

Neonates: May be treated with divided doses of calcium totaling about 2.4 mEq/kg daily.

Children: Usually, calcium dose of 0.5–0.7 mEq/kg administered IV 3 or 4 times daily or until tetany is controlled.

Exchange Transfusions of Citrated Blood IV

Neonates: 0.45 mEq of calcium concurrently with each 100 mL of citrated blood.

ACLS IV/IO

If calcium is indicated during pediatric resuscitation for treatment of hypocalcemia, calcium-channel blocker overdosage, hypermagnesemia, or hyperkalemia, experts recommend a dose of 0.272 mEq/kg administered slowly using calcium chloride. In critically ill children, calcium chloride may provide a greater increase in ionized calcium than calcium gluconate.

Adults

Dietary Requirements Oral

Calcium replacement requirements can be estimated by clinical condition and/or serum calcium determinations.

Prophylactic administration of calcium supplements may be necessary in some patients in order to maintain serum calcium >9 mg/dL.

The RDAs of elemental calcium for healthy adults are:

Adults 19–50 Years of Age:

RDA of 1 g daily.

Adults 51–70 Years of Age:

Men 51–71 years of age: RDA of 1 g daily.

Women 51–70 years of age: RDA of 1.2 g daily.

Adults >70 Years of Age:

RDA of 1.2 g daily.

Pregnant or Lactating Women:

Generally, the usual RDA of calcium appropriate for their age.

Hypocalcemia

Calcium gluconate usually is administered IV as a 10% solution and calcium chloride as a 2–10% solution.

Calcium replacement requirements can be estimated by clinical condition and/or serum calcium determinations.

Prevention Oral

Usually, about 1 g of elemental calcium daily.

Treatment Oral

Usually, 1–2 g or more of elemental calcium daily.

IM

Usually, 0.8 mEq of calcium as the calcium glycerophosphate and calcium lactate fixed-combination preparation 1–4 times weekly or as directed by a clinician.

Treatment When Prompt Elevation of Serum Calcium Is Required IV

Usual initial dose of 2.3–14 mEq of calcium; doses may be repeated every 1–3 days depending on the patient’s response.

Hypocalcemic Tetany IV

4.5–16 mEq doses of calcium, administered until therapeutic response occurs.

Exchange Transfusions of Citrated Blood IV

About 1.35 mEq of calcium concurrently with each 100 mL of citrated blood.

ACLS IV

If calcium is necessary during cardiac arrest, a dose of 0.109–0.218 mEq/kg (repeated as necessary) using calcium chloride has been recommended. Alternatively, 7–14 mEq of calcium as calcium chloride has been given. However, routine use not recommended. (See Uses.)

Hyperphosphatemia in Chronic Renal Failure Oral

Usual initial dose of 1.334 g of calcium acetate (338 mg of calcium) with each meal; increase dosage gradually according to serum phosphate concentrations, provided hypercalcemia does not occur.

Manufacturer states that most patients require about 2–2.67 g (about 500–680 mg of calcium) with each meal. However, some experts recommend limiting dosage of calcium provided by phosphate binders to ≤1.5 g daily and limiting total calcium intake (including dietary calcium) to ≤2 g daily; dialysis patients who remain hyperphosphatemic despite such therapy should receive a calcium-containing phosphate binder in combination with a non-calcium-, non-aluminum-, non-magnesium-containing phosphate binder.

Monitor serum calcium concentrations twice weekly during initiation of therapy and subsequent dosage adjustment; also monitor serum phosphorus concentrations periodically.

If hypercalcemia occurs, reduce dosage or withhold the salt. If severe hypercalcemia occurs, specific measures (e.g., hemodialysis) for the management of overdosage may be necessary.

Zollinger-Ellison Syndrome, Diagnosis IV

Usually, 0.25 mEq/kg of calcium per hour for a 3-hour period; serum gastrin concentrations are determined 30 minutes before the infusion, at the start of the infusion, and at 30-minute intervals thereafter for 4 hours.

In most patients with Zollinger-Ellison syndrome, preinfusion serum gastrin concentrations increase by more than 50% or by greater than 500 pg/mL during the infusion.

Magnesium Intoxication IV

Initially, 7 mEq of calcium; adjust subsequent doses according to patient response.

Medullary Thyroid Carcinoma, Diagnosis IV

Usually, about 7 mEq of calcium over 5–10 minutes; in patients with medullary thyroid carcinoma, plasma Calcitonin concentrations are elevated above normal basal concentrations.

Osteoporosis Oral

For prevention and treatment of osteoporosis, the National Osteoporosis Foundation recommends a calcium intake of 1 g daily in men 50–70 years of age, and a calcium intake of 1.2 g daily in women ≥51 years of age and men ≥71 years of age.

Special Populations

Hepatic Impairment

No specific dosage recommendations for hepatic impairment.

Renal Impairment

No specific dosage recommendations for renal impairment.

Geriatric Patients

No specific geriatric dosage recommendations.

Warnings

Contraindications

  • Ventricular fibrillation.
  • Hypercalcemia.
  • Hypophosphatemia.
  • Renal calculi.
  • IV administration contraindicated when serum calcium concentrations are above normal.

    • Warnings/Precautions

    Warnings

    Use calcium salts cautiously, if at all, in sarcoidosis, renal or cardiac disease, or patients receiving cardiac glycosides (see Digoxin under Interactions).

    Because it is acidifying, use calcium chloride cautiously in cor pulmonale, respiratory acidosis, renal disease, or respiratory failure.

    Non-lipid-soluble drugs (e.g., calcium) may injure the airway; avoid endotracheal administration.

    Calcium Monitoring

    Frequently perform determinations of serum calcium concentrations.

    Maintain serum calcium concentrations at 9–10.4 mg/dL (4.5–5.2 mEq/L). Some clinicians prefer to maintain serum calcium at slightly lower concentrations.

    Usually, do not allow serum calcium concentrations to exceed 12 mg/dL.

    Determinations of urine calcium are generally unreliable and hypercalciuria can occur in the presence of hypocalcemia. Forcing fluids may produce increased urine volume and thus prevent the formation of renal stones in patients with hypercalciuria.

    Citrated Blood Transfusion

    Administration of calcium in patients who have received transfusions of citrated blood may result in higher than normal total serum calcium concentrations. In these patients, however, most of the excess calcium is bound to citrate and is inactive; therefore, serious toxicity usually does not result.

    Discontinuing calcium when hypercalcemia occurs usually is sufficient to return serum calcium concentrations to normal.

    Local Effects

    Calcium salts are irritating to tissue when administered by IM or sub-Q injection and cause mild to severe local reactions including burning, necrosis and sloughing of tissue, cellulitis, and soft tissue calcification; venous irritation may occur with IV administration. (See IV Administration and also see IM or Sub-Q Injection, under Dosage and Administration.)

    IV Injection Effects

    Extravasation of calcium solution into surrounding tissues during IV injection can cause necrosis.

    Patients may complain of tingling sensations, a sense of oppression or heat waves, and a calcium or chalky taste following IV administration of calcium salts.

    Cardiovascular Effects

    Rapid IV injection of calcium salts may cause vasodilation, decreased BP, bradycardia, cardiac arrhythmias, syncope, and cardiac arrest.

    Inadvertent injection of calcium into the myocardium during attempted intracardiac injection into the ventricular cavity can result in lacerated coronary arteries, cardiac tamponade or pneumothorax, and intractable ventricular fibrillation may result.

    GI Effects

    Orally administered calcium salts may be irritating to the GI tract.

    Calcium salts are constipating.

    Calcium chloride, by any route of administration, produces more irritation than the other calcium salts and has been reported to cause GI hemorrhage when taken orally.

    Hypercalcemia

    Hypercalcemia is rarely produced by administration of calcium alone, but may occur with large doses in patients with chronic renal failure.

    Avoid overtreatment of hypocalcemia since hypercalcemia may be more dangerous than hypocalcemia.

    Mild hypercalcemia may be asymptomatic or manifest as constipation, anorexia, nausea, and vomiting, with mental changes such as confusion, delirium, stupor, and coma becoming evident as the degree of hypercalcemia increases.

    Mild hypercalcemia usually is readily controlled by reducing calcium intake (e.g., decreasing the dose of or avoiding supplemental calcium); more severe hypercalcemia may require specific management (e.g., hemodialysis).

    Dialysis patients with chronic renal failure receiving calcium salts may require adjustments in calcium concentrations in the dialysate to reduce the risk of hypercalcemia.

    Long-term effects of chronic calcium administration (e.g., for hyperphosphatemia in chronic renal failure) on progression of vascular or soft-tissue calcification is unknown.

    Renal Calculi

    High dietary intake of calcium has long been suspected as contributing to the risk of renal calculi, and restriction of calcium intake (i.e., low-calcium diets) had long been considered a reasonable measure in an attempt to prevent calculi formation in patients with idiopathic hypocalciuria.

    Recent evidence indicates that high dietary intake of calcium actually decreases the risk of symptomatic renal calculi, while intake of supplemental calcium may increase the risk of symptomatic stones.

    General Precautions

    Use of Fixed Combination

    When used in fixed combination with other agents, consider the cautions, precautions, and contraindications associated with the concomitant agents.

    Specific Populations

    Pregnancy

    Category C.

    Lactation

    Manufacturers state that it is not known whether calcium salts are distributed into milk, and to observe caution with parenteral therapy.

    Calcium is an important component of human milk in women not receiving supplemental calcium salts, and maternal calcium supplementation does not substantially affect milk calcium concentrations since the principal source is from maternal bone resorption.

    Pediatric Use

    Give calcium cautiously to children by IV route.

    Geriatric Use

    Calcium absorption (after oral administration) may be decreased in geriatric patients.

    Common Adverse Effects

    Constipation, nausea, vein irritation.

    What other drugs will affect Calcium Salts

    Consider the possibility that other drug interactions reported with antacids could occur.

    Specific Drugs and Laboratory Tests

    Drug or Test

    Interaction

    Comments

    Bisphosphonates, oral (e.g., alendronate, etidronate, ibandronate, risedronate)

    Concomitant administration may result in reduced bisphosphonate absorption

    Separate administration of the drugs

    Digoxin

    Inotropic and toxic effects are synergistic and arrhythmias may occur (particularly when calcium is given IV)

    Iron preparations, oral

    Concomitant administration may result in reduced iron absorption

    Advise patients to take the drugs at different times, whenever possible

    Levothyroxine

    Calcium carbonate may form insoluble chelate with levothyroxine, resulting in decreased levothyroxine absorption and increased serum thyrotropin concentrations

    Administer oral levothyroxine and calcium carbonate ≥4 hours apart

    Quinolones

    Concomitant administration of calcium salts and some fluoroquinolones (e.g., ciprofloxacin) may reduce oral bioavailability of the fluoroquinolone

    Recommended timing of fluoroquinolone administration relative to the calcium dose may vary depending on the specific fluoroquinolone preparation used

    Test, corticosteroids (Glenn-Nelson technique)

    Transient elevations of plasma 11-hydroxycorticosteroid concentrations with IV calcium, but concentrations return to control values after 1 hour

    Test, magnesium (serum and urine)

    False-negative values as measured by the Titan yellow method

    Tetracyclines

    Calcium complexes tetracycline antibiotics rendering them inactive

    Do not give the 2 drugs together orally nor should they be mixed for parenteral administration

    Thiazide diuretics

    Risk of hypercalcemia

    Avoid concomitant use

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