Calcium Gluconate for Symptomatic Hypocalcemia

Calcium Gluconate is required for the optimal functioning of skeletal muscles, neurons, and cardiac muscles. It is used as a dietary supplement for calcium supplementation when taken orally. Intravenously administered, it is used to treat symptomatic acute hypocalcemia

  • Off-Label Use of Calcium Gluconate in Adults include:

Calcium Gluconate Dose in Adults

Note:

  • Calcium gluconate 1 mg = Elemental calcium 93 mg
  • 10% or 100 mg/mL calcium gluconate contains 0.465 mEq/ml or 9.3 mg/mL of elemental calcium.

Use in the treatment of Hypocalcemia:

  • Mild hypocalcemia (ionized calcium of 4 - 5 mg/dL or 1 - 1.2 mmol/L):
    • 1 - 2 g Intravenous over 2 hours.
  • Moderate to severe (without seizure or tetany and ionized calcium of less than 4 mg/dL or less than 1 mmol/L):
    • 4 gms Intravenous over 4 hours
  • Severe symptomatic (symptomatic patients with seizure and tetany):
    • 1 - 2 g Intravenous over 10 minutes
    • The dose may be repeated hourly until symptoms resolve.
  • Continuous infusion:

    • 5 to 20 mg/kg/h Intravenous in hypoparathyroid patients

    • As soon as feasible, oral calcium supplementation and the active form of vitamin D (calcitriol or alfacalcidol), with or without ergocalciferol or cholecalciferol, should be started.

    • The oral therapy should be modified as the intravenous calcium is gradually discontinued.

Off-label dose for Hypocalcemia induced by citrate-based replacement fluid during continuous renal replacement therapy (CRRT):

Note:

Ionized calcium should be checked before to the start of CRRT, and calcium gluconate should be given until the level is greater than 4 mg/dL or greater  than 1 mmol/L.

A continuous sliding scale calcium gluconate infusion can be given while receiving CRRT in the following ways:

  • If ionized calcium is less than 3.6 mg/dL or less than 0.9 mmol/L:
    • Take expert opinion from a nephrologist
  • If ionized calcium is 3.6 - 4 mg/dL or 0.9 - 1 mmol/L:
    • Administer infusion at a rate of 1.4 gms/hour
  • If ionized calcium is 4 - 4.4 mg/dL or 1 - 1.1 mmol/L:
    • Administer infusion at a rate of 1.2 gms/hour
  • If ionized calcium is 4.4 - 5.2 mg/dL or 1.1 - 1.3 mmol/L:
    • Administer infusion at a rate of 1 gm/hour
  • If ionized calcium is more than 5.2 mg/dL or more than 1.3 mmol/L:
    • Notify the nephrologist.

Use of Calcium Gluconate for treating Cardiac arrest or cardiotoxicity with hyperkalemia, hypocalcemia, or hypermagnesemia:

  • 1.5 - 3 g Intravenous over 2 -  5 minutes

Calcium Gluconate Use in the maintenance requirement of Parenteral nutrition:

  • 10 to 20 mEq of intravenous calcium every day.
  • Depending on the levels of serum ionised calcium, the dose should be changed.

Off-label use for treating Calcium channel blocker overdose:

  • Hypotension and/ or conduction abnormalities:

    • Dosage of 60 mg/kg maximum dose of 3 to 6 g intravenously during a period of 5 to 10 minutes

    • The dose may be given three to four more times every 10 to 20 minutes

    • To increase blood pressure and contractility, a continuous infusion of 60 to 150 mg/kg/hour should be started and adjusted.

    • The aim should be to maintain twice-normal levels of ionised calcium.

    • When time is of the essence, 1 gm has been given every 2 to 3 minutes until clinical improvement is shown.

Off-label use in the treatment of Beta-blocker overdose:

  • Hypotension and or conduction disturbances:
    • 60 mg/kg intravenously given over 5–10 minutes, then an hour-long infusion of 60–150 mg/kg
    • The dose should be titrated to maintain an adequate hemodynamic response

Off-label use in the treatment of Hydrofluoric acid burns:

  • Subcutaneous 5% - 10% solution:
    • 0.5 mL/cm³ of burned tissue
    • Infiltration into the nearby healthy parts at a distance of 0.5 cm from the edge of the wounded tissue.
    • The dose may be repeated if pain recurs (resolution of pain is the end-point)

Note: Never administer calcium chloride subcutaneously.

  • Intra-arterial administration:
    • 50 mL of 5% Dextrose Water should be mixed with 10 mL of a 10% solution, and the mixture should be infused into the affected  area's supplying artery over the course of four hours.
    • By the end of the infusion, the pain usually resolves and may be repeated if the pain recurs.
    • Only experts should use this technique and extravasation should be avoided.
  • Inhalation as 2.5% nebulization solution:
    • Nebulize a 2.5% solution made by combining 1.5 mL of a 10% calcium gluconate solution with 4.5 mL of normal saline.

Calcium Gluconate dose in Children:

Adequate intake:

  • 1 - 6 months:
    • 200 mg/day of elemental calcium orally.
  • 7 - 12 months:
    • 260 mg/day of elemental calcium orally.

Recommended daily allowance (RDA):

  • 1 - 3 years:
    • 700 mg/day of elemental calcium orally.
  • 4 - 8 years:
    • 1,000 mg/day of elemental calcium orally.
  • 9 - 18 years:
    • 1,300 mg/day of elemental calcium orally.

Calcium Gluconate Use as maintenance requirement in Parenteral nutrition:

  • Infants and Children weighing 50 kgs or less :
    • 0.5 - 4 mEq/kg/day of elemental calcium Intravenous.
  • Children more than 50 kgs and Adolescents:
    • 10 - 20 mEq/day of elemental calcium Intravenous.

Calcium Gluconate in the treatment of Hypocalcemia:

  • General dosing:
    • Infants, Children, and Adults:

      • 200 to 500 mg/kg each day. Maximum intravenous dose of 1,000 mg/dose for babies and children and 2.0 gm–3.0 gm/dose for adolescents, administered intravenously as a continuous infusion or in 4 split doses.

  • Symptomatic patients (seizures or tetany):
    • Infants, Children, and Adults:
      • 100 - 200 mg/kg/dose Intravenous over 5 - 10 minutes
      • The usual adult dose is 1gm to 2 gms/dose
      •  After six hours, the dose can be given again, or 200 to 800 mg/kg/day can be given continuously.
  • Chronic therapy in asymptomatic patient:
    • Infants and Children:
      • 500 mg/kg/day orally in divided doses every 4 - 8 hours

Calcium Gluconate use for treating Rickets due to vitamin D deficiency:

  • Infants and Children:
    • 30 to 75 mg/kg/day of elemental calcium orally in three divided doses
    • Begin with a higher dose and titrate the dose downwards over a period of 2 - 4 weeks.

Use for treating Cardiac arrest with hyperkalemia or hypocalcemia, hypermagnesemia, or calcium channel blocker toxicity:

  • Infants, Children, and Adultsts:
    • 60 - 100 mg/kg/dose to a maximum dose of 3gms intravenous or intraosseus.
    • The dose may be repeated in 10 minutes if necessary.

Use for treating Calcium channel blocker toxicity by hypotension conduction disturbances:

  • Infants, Children, and Adultsts:
    • 60 mg/kg/dose intravenous or intraosseous administered over 30 - 60 minutes.
    • Calcium Chloride may increase serum calcium more rapidly in critically ill patients.

Calcium Gluconate Use in the treatment of Hydrofluoric acid burns:

  • Children and Adolescents:
    • Subcutaneous 5% - 10% solution:
      • 0.5 mL/cm³ of burned tissue
      • The area that is not affected should be infiltrated at a distance of 0.5 cm from the edge of the wounded tissue.
      • Repeat in case of pain. Pain resolution is therapeutic end-point.

Note: calcium chloride should never be injected subcutaneously.

  • Intra-arterial administration:
    • 50 mL of 5% Dextrose water should be mixed with 10 mL of a 10% solution, and the mixture should be infused into the affected aresupplying artery over the course of four hours.
    • The pain usually resolves by the end of the infusion. The infusion may be repeated if the pain recurs.
    • The intra-arterial mode of administration should only be used by professionals.

  • Inhalation as a 2.5% nebulization solution

    • Nebulize a 2.5% solution made by combining 1.5 mL of a 10% calcium gluconate solution with 4.5 mL of a 0.9% saline solution.

Pregnancy risk factor: C

  • It has not yet been tested in pregnant women.
  • Calcium chloride crosses over the placental boundary
  • Calcium requirements for pregnant and unpregnant women are identical.
  • It should only be used if indicated for cardiac arrhythmias.

Use during breastfeeding:

  • It can be found in breastmilk and can also be used by lactating mothers.
  • Both lactating and non-lactating women require calcium.

Dose in kidney disease:

  • Therapy should be initiated at a lower dose and the dose should be adjusted according to the serum calcium levels.

Dose in Liver disease:

  • Dose adjustment is not necessary in patients with liver disease.

Common Side Effects of Calcium Gluconate Include:

  • Cardiovascular:
    • Bradycardia
    • Arrhythmia
    • Cardiac arrest
    • Syncope
    • Decreased blood pressure
    • Vasodilation
  • Central nervous system:
    • Feeling hot
    • Anxiety
  • Gastrointestinal:
    • Unusual chalky taste
  • Neuromuscular & skeletal:
    • Tingling sensation

Contraindications to Calcium Gluconate include:

  • Digoxin toxicity, known or suspected.
  • Hypercalcemia
  • Ceftriaxone use in neonates concurrently

Warnings and Precautions

  • Extravasation:
    • Before and during infusion, ensure that the needle, cannula, or line is correctly placed.
    • Extravasation can cause severe necrosis or sloughing, so be sure to monitor the infusion site.
  • Hyperphosphatemia
    • It can cause soft tissue calcium-phosphate precipitation in patients with hyperphosphatemia.
  • Hypokalemia
    • If severe hypokalemia is treated, patients may experience life risking arrhythmias.
  • Hypomagnesemia:
    • Patients with refractory hypocalcemia should be treated for hypomagnesemia, a common kind of hypocalcemia.
  • Kidney stones and renal impairment
    • Patients with impaired renal function should not use it. The levels of the drug should be closely monitored.
    • Patients with a history kidney stone disease should avoid calcium supplements

Calcium gluconate: Drug Interaction

Note: Drug Interaction Categories:

  • Risk Factor C: Monitor When Using Combination
  • Risk Factor D: Consider Treatment Modification
  • Risk Factor X: Avoid Concomitant Use    

Risk Factor C (Monitor therapy).
Calcium Channel Blockers Calcium salts can lessen calcium channel blockers' therapeutic effects.
Cardiac Glycosides Cardiac Glycosides might have an arrhythmogenic effect that calcium salts can enhance.
DOBUTamine Dobbutamine may be affected by calcium salts.
Multivitamins/Minerals (with ADEK, Folate, Iron) It could elevate serum calcium salt levels.
Thiazide and Thiazide - Like Diuretics

Could reduce the excretion of calcium salts. Metabolic alkalosis may result from concurrent, ongoing usage.
Vitamin D Analogs Calcium salts can make vitamin D analogues more poisonous or have negative consequences.

Risk Factor D (Consider therapy modifications)

  
Alpha-Lipoic acid

The absorption of alpha-lipoic acid can be decreased by calcium salts. Calcium salts may not be absorbed as well when alpha-lipoic acid is present.
Bictegravir

Calcium salts have the potential to lower bictegravir serum levels.  Treatment: In fed settings, bictegravir and emtricitabine can be administered with calcium salts.  However, it is not advised for fasting to coadminister a calcium sodium salt with or two hours after it.
Bisphosphonate Derivatives

Polyvalent cation-containing items have the potential to reduce the serum concentration of bisphosphonate derivatives.  The following oral drugs should not be used within the following time frames: 2 hours before  or after tiludronate/clodronate/etidronate; 60 minutes after oral ibandronate; or 30 minutes after alendronate/risedronate.  There are two exceptions: pamidoate and zoledronic acid.
CefTRIAXone Intranavenous calcium salts may increase the toxic/adverse effects of CefTRIAXone. Ceftriaxone is a calcium-binding drug that forms an insoluble precipitate. Management: Ceftriaxone should not be used in neonates under 28 days old who need (or expect to need) IV calcium-containing treatments. Flush lines with compatible fluid after administration for older patients.
Deferiprone The serum concentration of Deferiprone may be decreased by products that contain polyvalent cations. Management: Deferiprone should be administered separately from oral medications and supplements containing polyvalent cations for at least four hours.
Dolutegravir

Calcium salts may lower the content of dolutegravir in the blood.  Dolutegravir needs to be taken at least two or six hours before calcium supplements.  Dolutegravir/rilpivirine should be administered at least 4 hours before or 6 hours after taking oral calcium salts.  Dolutegravir and oral calcium can both be taken with meals.
Eltrombopag

Products with polyvalent cations may lower the serum concentration of Eltrombopag.  Eltrombopag should be taken at least two hours before any product containing polyvalent cations.
Estramustine The absorption of estramustine might be decreased by calcium salts.
Multivitamins/Fluoride (with ADE)

The serum concentration may rise after using calcium salts.  Fluoride and multivitamin serum concentrations may be lowered by calcium salts (with ADE).  Fluoride absorption may be impaired by calcium salts.  Management: Avoid dairy products one hour before or two hours after fluoride administration. You should also avoid calcium-salt supplements and vitamins.
PenicillAMINE

Utilizing goods that include polyvalent cations can lower the serum levels of penicillAMINE. Treatment: Give oral polyvalent cation-containing products and penicillamines each at least an hour to work.
Supplements with phosphate Calcium salts can decrease the absorption rate of phosphate supplements. Management: This only applies to oral phosphate or calcium administration. The interaction may be minimized by administering oral phosphate supplement as well as oral calcium salts as close as possible. Sodium Glycerophosphate pentahydrate is an exception.
Quinolones Calcium salts can decrease Quinolones' absorption. Both agents can only be administered orally. LevoFLOXacin, Oral Inhalation; Moxifloxacin, Systemic.
Strontium Ranelate

Calcium salts may lower the serum levels of strontium ranelate.  Management: To reduce interactions, it's crucial to give strontium ranelate at least two hours apart from oral calcium salts.
Tetracyclines

Tetracycline levels in the serum can be lowered by calcium salts.  Management: It is worth thinking about separating the administration of oral calcium  and oral tetracyclines by a few hours if they cannot be avoided. The exception is eravacylin.
Thyroid Products Thyroid Products may be affected by calcium salts. Management: Keep the thyroid product and oral calcium supplement separated for at least four hours.
Trientine The serum concentration of Trientine may be decreased by products that contain polyvalent cations. Avoid taking trientine or other oral medications containing polyvalent cations at the same time. If required, give oral iron supplements a two-hour gap between each dose. It is necessary to administer oral polyvalent cations separately.

Risk Factor X (Avoid Combination)

  
BaloxavirMarboxil BaloxavirMarboxil serum concentration may be decreased by products that contain polyvalent Cation.
Calcium Acetate Calcium Salts can increase the toxic/adverse effects of Calcium Acetate.

Monitor:

  • Serum calcium 4 hourly when administered as an intermittent infusion or every 1 - 4 hours when administered via continuous infusion
  • Serum albumin
  • Serum phosphate
  • Serum magnesium
  • Monitor the infusion site
  • Vitals signs and ECG

Overdose of Calcium channel blocker and beta-blocker:

  • Monitor vital signs

  • Every 30 minutes at first, then every two hours, serum ionised calcium levels are measured. (keep ionised calcium levels in the upper ranges  at no more than twice the ULN)

  • Keep your hypercalcemia mild.

How to administer Calcium Gluconate?

  • The oral formulation should be taken after meals or with lots of fluids.
  • A 200 mg/minute maximum intravenous bolus injection rate is recommended.
  • The rate of infusion should be adjusted as needed based on the serum calcium levels.
  • It should not be administered as an Intramuscular injection as it is a vesicant.
  • Proper line or cannula placement should be ensured to avoid extravasation.

Refrain from letting the liquids leak out. Extravasation should be carefully aspirated after the infusion is stopped right away (leave the needle  or cannula in place).

DO NOT FLUSH THE LINE!

Early calcium extravasation management:

  • Start the hyaluronidase antidote medication. Use a 25-gauge needle to inject a total of 1 to 1.7 mL (15 units/mL)  as five separate 0.2 to 0.3 mL intradermal or subQ injections into the region of extravasation at the leading edge.

  • The catheter that generated the infiltration may also be used to inject hyaluronidase.

  • Take out the cannula or needle

  • Use cold, dry compresses.

  • Raising the extremity

Calcium extravasation delayed:

  • Keep an eye on the website. Most calcifications disappear on their own.

  • The use of sodium thiosulfate antidote may be necessary in severe cases of calcinosis cutis, though.

Sodium thiosulfate:

  • It is administered intravenously in a dose of 12.5 gms over 30 minutes.
  • The dose may be increased gradually to 25 gms thrice weekly.
  • Hypocalcemia, nausea, and non-anion gap acidosis should all be kept an eye on in the patient.

Hydrofluoric acid burns treatment

Subcutaneous infiltration:

  • It should be infiltrated into the distal point of injury and infiltrated directly via a 27- or 30-gauge needle into the subcutaneous tissue.
  • As excessive administration might cause compartment syndrome and worsen tissue injury, it should be avoided.

Intra-arterial administration:

  • This method should be used only by experts. An arterial catheter should be placed and infused over four hours.
  • Care should be taken to avoid extravasation of calcium gluconate.

Inhalation:

  • Administer via nebulization as a diluted sample of 2.5 % calcium gluconate solution.

Mechanism of action of Calcium Gluconate:

  • It controls the action potential excitation, and is essential for optimal neuronal performance and muscle performance.
  • It can also be used to correct fluoride-induced hypocalcemia.

It isabsorbedIn very small amounts, unless you take it in large doses with vitamin D.

AbsorptionIt is further affected by achlorhydria and renal osteodystrophy as well as malabsorption.

AbsorptionIt is doubled in pregnancy and increases in acidic environments. It isdistributedIt is found primarily in the bones, teeth, and 40% bound to albumin. It is excreted in the feces as unabsorbed Calcium.

Calcium gluconate International Brands:

  • Biogam Ca
  • Calcedon
  • Calcii Gluconas
  • Calcimusc
  • Calcinate
  • Calcio
  • Gluconato
  • Calcium Braun
  • Calcium Gluconate
  • Calcium Gluconicum
  • Calcium Pliva
  • Calcium Polfa
  • Folinex 50
  • Glucal
  • Gluconate de Calcium Lavoisier
  • Novacalc

Calcium Gluconate brands in Pakistan:

Calcium Gluconate [Syrup 4 g/5ml]
CALCIUM ARCO PAKISTAN PHARMACEUTICAL PRODUCTS (PVT) LTD.

Calcium Gluconate [Sachet 1 g]
CALCIUM C-1000 EURO PHARMA INTERNATIONAL
VITASCOT SCOTMANN PHARMACEUTICALS

Calcium Gluconate [Sachet 100 mg]
ORA-C SAYDON PHARMACEUTICAL INDUSTRIES (PVT) LTD.

Calcium Gluconate [Sachet 250 mg]
CAL-V-CON HELICON PHARMACEUTEK PAKISTAN (PVT) LTD.

Calcium Gluconate [Sachet 422 mg]
KLCM FORTE 1000 DAVIS PHARMACEUTICAL LABORATORIES

Calcium Gluconate [Tabs 500 mg]
PARAGIN-C HELICON PHARMACEUTEK PAKISTAN (PVT) LTD.

Calcium Gluconate [Powder 1 g/sachet]
OSSO-C PARAMOUNT PHARMACEUTICALS

Calcium Gluconate [Powder 578 mg/sachet]
VITACAL 1000+C CIRIN PHARMACEUTICALS (PVT) LTD.
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