Generic Phoslo

CALCIUM
Indications
Oral: As a dietary supplement when calcium intake may be inadequate.
In the treatment of calcium deficiency states that may occur in diseases such as:
Tetany of newborn; end-stage renal disease, mild to moderate renal insufficiency; renal osteodystrophy; acute and chronic hypoparathyroidism; pseudohypoparathyroidism; postmenopausal and senile osteoporosis; rickets and osteomalacia. Some studies have suggested that the use of calcium citrate is more effective than calcium carbonate in the treatment of postmenopausal osteoporosis.
Calcium acetate (PhosLo) - Control of hyperphosphatemia in end-stage renal failure; does not promote aluminum absorption.
Parenteral:
Hypocalcemia - For a prompt increase in plasma calcium levels (e.g., neonatal tetany and tetany due to parathyroid deficiency, vitamin D deficiency, alkalosis); prevention of hypocalcemia during exchange transfusions; conditions associated with intestinal malabsorption.
Calcium chloride and gluconate - Adjunctive therapy in the treatment of insect bites or stings, such as Black Widow spider bites to relieve muscle cramping; sensitivity reactions, particularly when characterized by urticaria; depression due to over-dosage of magnesium sulfate; acute symptoms of lead colic; rickets; osteomalacia.
Calcium chloride - To combat the deleterious effects of severe hyperkalemia as measured by ECG, pending correction of increased potassium in the extracellular fluid. Cardiac resuscitation: Particularly after open heart surgery, when epinephrine fails to improve weak or ineffective myocardial contractions.
Calcium gluconate - To decrease capillary permeability in allergic conditions, non-thrombocytopenic purpura and exudative dermatoses such as dermatitis herpetiformis; for pruritus of eruptions caused by certain drugs; in hyperkalemia, calcium gluconate may aid in antagonizing the cardiac toxicity, provided the patient is not receiving digitalis therapy.
Unlabeled uses:
Oral - Calcium supplementation may lower blood pressure in some hypertensive patients with indices suggesting calcium "deficiency." However, other hypertensives may experience a pressor response.
In one study, calcium administration significantly reduced premenstrual symptoms of fluid retention, pain, and negative affect.
Parenteral - Calcium salts have been used to treat verapamil overdose, treat acute hypotension from verapamil, and prevent initial hypotension in patients requiring verapamil for whom decreases in blood pressure could be detrimental.

Administration and Dosage
Oral: Calcium must be in a soluble, ionized form to be absorbed. Solubility (except calcium lactate) is increased by acidic pH. Give with meals to maximize acidity and solubility.
Dietary supplement - The usual daily dose is 500 mg to 2 g, 2 to 4 times/day. An NIH Consensus Development conference recommends a calcium intake for adults of 1000 to 1500 mg/day to reduce bone loss associated with aging.
PhosLo - 2 tablets with each meal. The dosage may be increased to bring the serum phosphate value Parenteral: Calcium gluconate is generally preferred over calcium chloride as it is less irritating.
IV - Warm solutions to body temperature and give slowly (0.5 to 2 mL/min); stop if patient complains of discomfort. Resume when symptoms disappear. Following injection, patient should remain recumbent for a short time. Repeated injections may be needed because of the rapid calcium excretion. Inject calcium chloride and gluconate through a small needle into a large vein to minimize venous irritation.
IM administration - IM administration of calcium gluceptate and gluconate may be tolerated; however, reserve this route for emergencies when technical difficulty makes IV injection impossible. Administer calcium gluconate only by the IV route and calcium chloride by the IV or intraventricular route.
Calcium chloride -
For IV use only: Injection is irritating to veins and must not be injected into tissues, because severe necrosis and sloughing may occur. Avoid extravasation. Administer slowly (not to exceed 0.5 to 1 mL/min).
Intraventricular administration - In cardiac resuscitation, injection may be made into the ventricular cavity; do not inject into the myocardium. Intraventricular injection may be administered by personnel who are well trained in the technique and familiar with possible complications. Break off the IV needle supplied with the syringe and replace with a suitable intracardiac needle by affixing it firmly to the Luer taper provided on the syringe. After the injection has been completed, remove the needle/syringe assembly from the injection site by grasping the needle at the Luer fitting.
The intraventricular dose usually ranges from 200 to 800 mg (2 to 8 mL).
Hypocalcemia disorders:
Adults - 500 mg to 1 g at intervals of 1 to 3 days, depending on response of patient or serum calcium determinations. Repeated injections may be required.
Children -0.2 mL/kg up to 1 to 10 mL/day.
Magnesium intoxication: Give 500 mg promptly; observe patient for signs of recovery before further doses are given.
Hyperkalemic ECG disturbances of cardiac function: Adjust dosage by constant monitoring of ECG changes during administration.
Cardiac resuscitation:
Adults - Dose ranges from 500 mg to 1 g IV or 200 to 800 mg injected into the ventricular cavity.
Children - 0.2 mL/kg
Calcium gluceptate -
IM: 2 to 5 mL (0.44 to 1.1 g). Inject 5 mL (1.1 g) doses in the gluteal region or, in infants, in the lateral thigh.
IV: 5 to 20 mL (1.1 to 4.4 g). Warm solution to body temperature and administer slowly ( Exchange transfusions in newborns: 0.5 mL (0.11 g) after every 100 mL of blood exchanged.
Calcium gluconate - For IV use only, directly or by infusion; SC or IM injection may cause severe necrosis and sloughing. Do not exceed a rate of 0.5 to 2 mL/min. Calcium gluconate may also be administered by intermittent infusion at a rate not exceeding 200 mg/min, or by continuous infusion. Discontinue injection if the patient complains of discomfort. Do not use IM, as abscess formation and local necrosis may occur.
Adults: 2.3 to 9.3 mEq (5 to 20 mL) as required. Dosage range is 4-65 to 70 mEq/ day.
Children: 2.3 mEq/kg/day or 56 mEq/m2/day, well diluted; give slowly in divided doses.
In/ants: Not more than 0.93 mEq (2 mL).
Emergency elevation of serum calcium:
Adults - 7 to 14 mEq (15 to 30.1 mL) IV.
Children - 1 to 7 mEq (2.2 to 15 mL).
Infants - Hypocalcemia tetany:
Adults - 4-5 to 16 mEq of calcium (9.7 to 34-4 mL) may be given IM until therapeutic response occurs.
Children - 0.5 to 0.7 mEq/kg (1.1 to 1.5 mL/kg) IV 3 or 4 times/day or until tetany is controlled.
Neonates - 2.4 mEq/kg/day (5.2 mL/kg/day) in divided doses.
Hyperkalemia with secondary cardiac toxicity: Administer IV to provide 2.25 to 14 mEq (4-8 to 30.1 mL) while monitoring ECG. If necessary, repeat doses after 1 to 2 minutes.
Magnesium intoxication:
Adults - Initial dose is 4-5 to 9 mEq (9.7 to 19.4 mL) IV. Adjust subsequent doses to patient response. If IV use is not possible, give 2 to 5 mEq (4-3 to 10.8 mL) IM.
Exchange transfusion:
Adults - Approximately 1.35 mEq (2.9 mL) IV concurrent with each 100 mL of citrated blood.
Neonates - Administer IV at a dosage of 0.45 mEq (1 mL)/100 mL of exchanged citrated blood.
Admixture incompatibilities: Calcium salts should not generally be mixed with carbonates, phosphates, sulfates, or tartrates in parenteral admixtures; they are conditionally compatible with potassium phosphates, depending on concentration. Calcium ions will chelate tetracycline.

Actions
Pharmacology: Calcium is essential for the functional integrity of the nervous and muscular systems, for normal cardiac contractility and the coagulation of blood. It also functions as an enzyme cofactor and affects the secretory activity of endocrine and exocrine glands. Normal levels are 8.5 to 10.5 mg/dL.
Hypocalcemia -
Symptoms: Tetany; paresthesias; laryngospasm; muscle spasms; seizures (usually grand mal); irritability; depression; psychosis; prolonged QT interval; intestinal cramps and malabsorption; respiratory arrest. Prolonged hypocalcemia may be associated with ectodermal defects including the nails, skin, and teeth.
Pharmacokinetics: Differences in absorption and bioavailability between various calcium salts appear to exist, as well as between different preparations of the same salt.
Approximately 80% of body calcium is excreted in the feces as insoluble salts; urinary excretion accounts for the remaining 20%.

Contraindications
Oral: Renal calculi; hypophosphatemia; hypercalcemia.
Parenteral: Hypercalcemia; ventricular fibrillation; digitalized patients.

Warnings
Extravasation: Calcium chloride and gluconate can cause severe necrosis, sloughing, and abscess formation with IM or SC administration.
PhosLo: End-stage renal failure patients may develop hypercalcemia when given calcium with meals. Do not give other calcium supplements concurrently with PhosLo. Monitor serum calcium levels twice weekly during the early dose adjustment period. Do not allow serum calcium times phosphate product to exceed 66.
Pregnancy: Category C. (PhosLo and parenteral).

Precautions
Oral:
Hypercakemia/hypercalciuria - Hypercalcemia/hypercalciuria may result when therapeutic amounts are given for prolonged periods. Avoid by frequent monitoring of plasma and urine calcium levels.
Parenteral:
Cardiovascular effects - Prevent a high concentration of calcium from reaching the heart because of the danger of cardiac syncope.

Drug Interactions
Calcium citrate: Avoid concurrent aluminum-containing antacids.
Drugs that may affect calcium include thiazide diuretics.
Drugs that may be affected by calcium include atenolol, sodium polystyrene sulfonate, tetracyclines, and verapamil.
Oral only: Iron salts, quinolones; parenteral only: Digitalis glycosides.
Drug/Lab test interactions: Transient elevations of plasma 11-hydroxy-corticosteroid levels (Glenn-Nelson technique) may occur when IV calcium is administered, but levels return to control values after 1 hour. In addition, IV calcium gluconate can produce false-negative values for serum and urinary magnesium.
Drug/Food interactions: Diets high in dietary fiber have been shown to decrease absorption of calcium due to decreased transit time in the GI tract and complexing of fiber with the calcium.
Calcium acetate, when taken with meals, combines with dietary phosphate to form insoluble calcium phosphate which is excreted in the feces.

Adverse Reactions
Oral -GI disturbances are rare. Mild hypercalcemia (Ca > 10.5 mg/dL) may be asymptomatic or manifest itself as: Anorexia; nausea; vomiting; constipation; abdominal pain; dry mouth; thirst; polyuria. More severe hypercalcemia (Са++12 mg/dL) is associated with confusion, delirium, stupor, and coma.
The risk of hypercalcemia with calcium acetate may be less than that of calcium carbonate and calcium citrate.
IM administration - Mild local reactions may occur (calcium gluceptate). Local necrosis and abscess formation may occur with calcium gluconate, and severe necrosis and sloughing may occur with IM or SC administration of calcium chloride.
IV administration - Rapid IV administration may cause bradycardia, sense of oppression, tingling, metallic, calcium, or chalky taste, or "heat waves". Rapid IV 'calcium gluconate may cause vasodilation, decreased blood pressure, cardiac arrhythmias, syncope, and cardiac arrest. Calcium chloride injections cause peripheral vasodilation and a local burning sensation; blood pressure may fall moderately.
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