Calcium gluconate is the calcium salt of gluconic acid. Calcium is the most abundant cation and the fifth most common inorganic element in the human body. Calcium is essential for the maintenance of the nervous, muscular, and skeletal systems, and for cell membrane and capillary permeability. Its role in bone structure and muscle contraction is well known, but calcium is also important for blood coagulation, nerve conduction, and electrical conduction in the myocardium. In general, calcium salts are used to treat or prevent calcium depletion. Calcium is used for the temporary control of cardiac arrhythmias; however, intravenous calcium is recommended for the treatment of cardiac arrest or life-threatening cardiac arrhythmias only when associated with hypocalcemia, hyperkalemia, or hypermagnesemia. Calcium gluconate contains less elemental calcium than calcium chloride (9% elemental calcium versus 27%) and is usually not the preferred salt form for use in acute hypocalcemia in emergent situations; however, calcium gluconate is usually preferred in the nonarrest setting for mild to moderate, asymptomatic hypocalcemia due to the lower potential for infusion site reactions compared with calcium chloride. Calcium is recognized as an important agent in preventing osteoporosis, especially in postmenopausal women. However, calcium gluconate as a dietary supplement is not practical due to the small concentration of elemental calcium contained in the tablets.
General Administration Information
For storage information, see the specific product information within the How Supplied section.
Route-Specific Administration
Oral Administration
Oral Solid Formulations
-In general, administer with meals for improved absorption. Follow each dose with adequate fluids.
-Because calcium-containing products may interfere with the absorption of other medicines, separate administration of calcium from other medications according to recommendations for the potentially interacting medication.
Oral Liquid Formulations
-The parenteral formulation of calcium gluconate has been diluted in feedings for oral administration in neonates and infants.
Injectable Administration
-Administer intravenously. Do NOT administer intramuscularly or subcutaneously.
-Visually inspect parenteral products for particulate matter and discoloration prior to administration whenever solution and container permit.
-Calcium gluconate 10% (100 mg/mL) contains approximately 9 mg/mL of elemental calcium.
Intravenous Administration
Intermittent IV Infusion
-Vials: Dilute in compatible IV solution (i.e., 0.9% Sodium Chloride Injection, 5% Dextrose Injection) to a usual concentration of 10 to 50 mg/mL.
-Pharmacy bulk vial: Use contents within 4 hours after the container is penetrated. Each dose must be used immediately.
-Pre-mixed Bags in Sodium Chloride Injection:
--Do not dilute prior to use or add supplementary medications to the bag.
-Do not use the infusion bag in series connections.
-Single-dose container; discard any unused portion.
-Neonates: A recommended concentration for peripheral lines is 3 mg/mL for neonates; however, concentrations as high as 100 mg/mL have been used for bolus doses. Observe the infusion line closely. Higher concentrations have been given via central lines.
-Generally, infuse over 10 to 60 minutes.
--Adults: Do not exceed a rate of 200 mg/minute.
-Pediatrics: Do not exceed a rate of 100 mg/minute.
IV Push
-In general, inject IV 10% calcium gluconate slowly, at a rate not exceeding 200 mg/minute in adults and 100 mg/minute in pediatric patients to avoid adverse reactions. However, for life-threatening cardiac arrhythmias during cardiopulmonary resuscitation, bolus doses are given over 2 to 5 minutes.
Continuous IV Infusion
-Vials: Dilute in compatible IV solution (i.e., 0.9% Sodium Chloride Injection, 5% Dextrose Injection) to a usual concentration of 5.8 to 10 mg/mL.
Other Injectable Administration
Intraosseous Administration
NOTE: Calcium gluconate is not FDA-approved for intraosseous administration.
-During cardiopulmonary resuscitation, the same dosage may be given via the intraosseous route if IV access is unsuccessful or not feasible.
Calcium gluconate irritates tissue when given by IV injection and an injection site reaction, characterized by mild to severe local irritation and soft tissue inflammation, can occur. Intravenous administration of calcium gluconate in patients with local trauma may result in calcinosis cutis due to a transient increase in local calcium concentrations. Calcinosis cutis may occur with or without extravasation of calcium gluconate and is characterized by abnormal dermal calcium deposits. Symptoms may include papules, plaques, or nodules associated with erythema, swelling, or induration. Tissue necrosis, ulceration (skin ulcer), and secondary infection are the most serious complications. Caution should be taken to avoid extravasation or accidental injection into perivascular tissues. If extravasation occurs or clinical manifestations of calcinosis cutis occur, immediately discontinue IV administration of calcium gluconate and treat as needed.
Hypercalcemia may occur with excess intake of calcium. It rarely occurs if appropriate doses of calcium are administered to otherwise healthy patients; however, patients with renal failure, patients receiving vitamin D, patients with electrolyte imbalance (i.e., hyponatremia, hyperkalemia), and patients with prolonged immobility can develop hypercalcemia readily. Signs and symptoms of hypercalcemia include anorexia, constipation, nausea/vomiting, drowsiness, hypertension, polyuria, and premature ventricular contractions (PVCs). Severe hypercalcemia (calcium concentrations more than 12 mg/dL) may result in confusion, delirium, stupor, and coma. Concentrations more than 15 mg/dL may be life-threatening. Calcium gluconate injection can cause hypotension (dizziness and syncope), flushing, nausea/vomiting, tingling sensation (i.e., paresthesias), and a calcium or chalky taste (i.e., dysgeusia). Rapid IV injection can cause peripheral vasodilation, sinus bradycardia or AV block, cardiac arrhythmias (including ventricular fibrillation), and/or cardiac arrest, especially in the digitalized patient. Cardiac monitoring is recommended during rapid IV injection and in digitalized patients to avoid serious cardiac adverse events.
A rare, but serious, side effect of calcium therapy is calcific nephrolithiasis.
Calcium gluconate injection contains aluminum. Thus, aluminum toxicity may occur with prolonged administration in high-risk patients, including those with renal impairment and premature neonates. Premature neonates are at particular risk for aluminum toxicity because of immature renal function and they require large amounts of calcium and phosphate solutions, which contain aluminum. Research indicates that patients with renal impairment, who receive parenteral aluminum at rates greater than 4 to 5 mcg/kg/day, may develop aluminum toxicity (CNS and bone toxicity). Tissue loading may occur at lower administration rates.
Calcium gluconate is contraindicated in patients with hypercalcemia.
Calcium gluconate is not recommended for routine use during cardiopulmonary resuscitation, except when indications exist to counterbalance electrolyte disturbances. Calcium gluconate should not be used in patients with digitalis toxicity because of an increased risk of developing cardiac arrhythmias. Cardiac glycosides and calcium gluconate both increase intracellular calcium, so calcium gluconate can worsen digitalis toxicity. Cardiac glycoside therapy, however, does not preclude the use of calcium gluconate. Rapid infusion of calcium gluconate injection may cause vasodilation, hypotension, bradycardia, cardiac arrhythmias, syncope, and cardiac arrest. To avoid serious reactions, dilute calcium gluconate injection prior to administration and infuse slowly. If rapid IV bolus injection is needed, generally do not exceed a rate of 200 mg/minute in adults and 100 mg/minute in pediatric patients; however, for life-threatening cardiac arrhythmias during cardiopulmonary resuscitation, bolus doses are given over 2 to 5 minutes. Monitor ECG during administration to avoid serious cardiac adverse events.
Calcium gluconate should not be given by intramuscular administration or subcutaneous administration. Severe necrosis and sloughing may occur. Intravenous administration of calcium gluconate and local trauma may also result in calcinosis cutis due to a transient increase in local calcium concentrations. Calcinosis cutis may occur with or without extravasation of calcium gluconate and is characterized by abnormal dermal calcium deposits. Symptoms may include papules, plaques, or nodules associated with erythema, swelling, or induration. Tissue necrosis, ulceration, and secondary infection are the most serious complications. Caution should be taken to avoid extravasation or accidental injection into perivascular tissues. If extravasation occurs or clinical manifestations of calcinosis cutis occur, immediately discontinue IV administration of calcium gluconate and treat as needed.
Calcium gluconate should be used with caution in patients with chronic renal failure due to the increased risk of developing hypercalcemia. Additionally, calcium gluconate formulations contain aluminum (content varies with formulation). Thus, aluminum may reach toxic concentrations with prolonged administration in patients with renal impairment. Premature neonates are at particular risk for aluminum toxicity because of immature renal function and they require large amounts of calcium and phosphate solutions, which contain aluminum. Research indicates that patients with renal impairment, including neonates, who receive parenteral aluminum at rates greater than 4 to 5 mcg/kg/day may accumulate aluminum at concentrations associated with central nervous system and bone toxicity. Tissue loading may occur at lower administration rates.
Calcium gluconate should be used cautiously, if at all, in patients with vitamin D toxicity or hyperparathyroidism. Hypercalcemia is likely to occur in either of these conditions.
Calcium gluconate should be used with caution in patients with preexisting hypercalciuria or nephrolithiasis, especially if renal calculi are present.
Calcium gluconate should be used with caution in patients with sarcoidosis as hypercalcemia is more likely to occur in these patients.
Calcium-containing IV solutions are contraindicated in neonates who require coadministration of ceftriaxone due to cases of fatal outcomes in which ceftriaxone-calcium precipitates in the lung and kidneys have been reported in both term and premature neonates. In older patients, ceftriaxone and calcium-containing IV solutions may be used concomitantly; however, ceftriaxone must NOT be mixed or administered simultaneously with calcium-containing IV solutions, even via a Y-site or different infusion line at different sites.
Limited data with calcium gluconate use during human pregnancy are insufficient to determine a drug associated risk of adverse developmental outcomes. However, there are risks to the mother and fetus associated with hypocalcemia in pregnancy.
Calcium is present in human milk as a natural component. However, there are no data available on the effects of calcium gluconate on calcium concentrations in human milk, the effect on the breastfed infant, or the effect on milk production. Consider the benefits of breast-feeding, the risk of infant drug exposure, and the risk of an untreated or inadequately treated condition.
General Dosing Information
-Calcium gluconate is 9.3% elemental calcium, which is equivalent to 93 mg of elemental calcium (4.65 mEq) per gram of calcium gluconate.
For the treatment of hypocalcemia, including tetany due to hypocalcemia:
-for the treatment of acute or symptomatic hypocalcemia (i.e., tetany):
Intravenous dosage:
Adults: 1 to 2 g IV every 6 hours as needed as determined by serum calcium concentrations and patient response. Doses as high as 4 g IV infused over 4 hours have been used. Alternatively, 5.4 to 21.5 mg/kg/hour continuous IV infusion may be administered if symptoms recur after initial IV calcium replacement. Titrate dose based on serum calcium concentrations.
Infants, Children, and Adolescents: 100 to 200 mg/kg/dose (Max: 2 g/dose) IV every 6 hours as needed as determined by serum calcium concentrations and patient response. The FDA-approved dose is 29 to 60 mg/kg/dose IV every 6 hours as needed. Alternatively, 8 to 13 mg/kg/hour continuous IV infusion may be administered if symptoms recur after initial IV calcium replacement. Titrate dose according to serum calcium concentrations.
Neonates: 100 to 200 mg/kg/dose IV every 6 hours as needed as determined by serum calcium concentrations and patient response. Alternatively, 17 to 33 mg/kg/hour continuous IV infusion may be administered if symptoms recur after initial IV calcium replacement. Titrate dose according to serum calcium concentrations. In neonates, continuous infusion of calcium is preferred to IV bolus doses.
-for the maintenance treatment of hypocalcemia:
NOTE: Calcium gluconate is not the preferred salt form because it contains a much lower concentration of elemental calcium compared with calcium carbonate. However, the IV preparation of calcium gluconate may be given orally if other options are unavailable.
Oral dosage*:
Infants, Children, and Adolescents: 30 to 100 mg/kg/day elemental calcium PO in 3 to 4 divided doses. Titrate dose based on symptom control and target calcium concentrations.
Neonates: 40 to 100 mg/kg/day elemental calcium PO in 4 to 6 divided doses. Titrate dose based on symptom control and target calcium concentrations.
For the treatment of cardiotoxicity or cardiac arrest* associated with hyperkalemia, hypermagnesemia, or ionized hypocalcemia, including during cardiopulmonary resuscitation*:
NOTE: Calcium gluconate is not recommended for routine treatment of cardiopulmonary arrest in the absence of documented hypocalcemia, calcium-channel blocker overdose, hypermagnesemia, or hyperkalemia. No benefit has been demonstrated for routine use during cardiac arrest and hypercalcemia may occur after calcium administration. The use of calcium during pediatric cardiopulmonary resuscitation has been associated with decreased survival and poor neurologic outcomes.
Intravenous or Intraosseous* dosage:
Adults: 1,500 to 3,000 mg (15 to 30 mL of a 10% solution) IV or IO; may repeat dose if needed.
Infants, Children, and Adolescents: 60 to 100 mg/kg/dose (0.6 to 1 mL/kg/dose; Max: 2 g/dose) IV or IO; may repeat dose if needed. Calcium chloride is the preferred salt because it is in the ionized form and leads to a greater increase in ionized calcium; however, calcium gluconate may be used if calcium chloride is unavailable.
Neonates: 60 to 100 mg/kg/dose (0.6 to 1 mL/kg/dose) IV or IO; may repeat dose if needed. Calcium chloride is the preferred salt because it is in the ionized form and leads to a greater increase in ionized calcium; however, calcium gluconate may be used if calcium chloride is unavailable.
For nutritional supplementation:
-for nutritional supplementation to prevent hypocalcemia and maintain nutritional status in patients receiving parenteral nutrition (PN)*:
NOTE: Calcium gluconate is the preferred salt for PN formulations.
Intravenous dosage:
Adults: 10 to 15 mEq/day IV. Total calcium amounts may be limited due to calcium/phosphate incompatibility. Individualize dosing according to monitoring.
Children weighing 50 kg or more and Adolescents: 10 to 20 mEq/day IV. Total calcium amounts may be limited due to calcium/phosphate incompatibility. Individualize dosing according to monitoring.
Infants and Children weighing 50 kg or less: 0.5 to 4 mEq/kg/day IV. Total calcium amounts may be limited due to calcium/phosphate incompatibility. Individualize dosing according to monitoring.
Neonates: 2 to 4 mEq/kg/day IV. Higher calcium requirements are necessary in premature and term neonates compared with older children; however, total calcium amounts may be limited due to calcium/phosphate incompatibility. Individualize dosing according to monitoring.
-for nutritional supplementation to provide the recommended dietary allowance (RDA) in healthy individuals:
NOTE: Although indicated as a dietary supplement, oral calcium gluconate tablets are not considered practical in clinical practice due to the low elemental calcium content. One 500-mg tablet of calcium gluconate only provides 9% elemental calcium, or approximately 45 mg; therefore, many tablets would be necessary to reach desirable daily dose.
Oral dosage:
Adult Females 51 years and older: 1,200 mg/day elemental calcium PO is the recommended dietary allowance (RDA). Guidelines for the prevention osteoporosis in postmenopausal females recommend a target daily intake of 1,200 mg/day of elemental calcium given with a regimen including vitamin D to promote general bone health. There is insufficient evidence to determine if daily supplementation with calcium at doses greater than 1,000 mg and vitamin D at doses greater than 10 mcg (400 international units) prevents fractures in community-dwelling postmenopausal females.
Adult Females 19 to 50 years: 1,000 mg/day elemental calcium PO is the recommended dietary allowance (RDA).
Adult Males 71 years and older: 1,200 mg/day elemental calcium PO is the recommended dietary allowance (RDA).
Adult Males 19 to 70 years: 1,000 mg/day elemental calcium PO is the recommended dietary allowance (RDA).
Adults 18 years: 1,300 mg/day elemental calcium PO is the recommended dietary allowance (RDA).
For transfusion-induced hypocalcemia prophylaxis*:
-for citrated blood transfusion-induced hypocalcemia prophylaxis:
Intravenous dosage:
Adults: 300 mg (approximately 1.4 mEq elemental calcium) IV for each 100 mL of citrated blood infused.
Infants, Children, and Adolescents: 300 mg (approximately 1.4 mEq elemental calcium) IV for each 100 mL of citrated blood infused.
-for exchange transfusion-induced hypocalcemia prophylaxis:
Intravenous dosage:
Neonates: 98 mg (0.465 mEq elemental calcium) IV for each 100 mL of citrated blood exchanged has been used. However, studies have reported that although decreases in ionized calcium concentrations occurred during exchange transfusion, the decreases were transient and normalized spontaneously and hypocalcemia as a complication did not occur in groups who did not receive calcium supplementation. One study in 18 neonates found no difference in ionized calcium concentrations between patients who received calcium gluconate and those who did not. Studies have suggested that routine supplementation is not necessary in most patients and supplementation should be considered in high-risk patients (i.e., very low birth weight infants with complicated history and repeated exchange transfusions).
For the treatment of calcium-channel blocker toxicity*:
Intravenous dosage:
Adults: 3,000 to 6,000 mg (30 to 60 mL of a 10% solution) IV over 5 minutes; may repeat every 10 to 20 minutes for an additional 3 to 4 doses or consider an infusion of 60 to 150 mg/kg/hour (0.6 to 1.5 mL/kg/hour) IV. Titrate to effect and administer additional boluses as needed.
Infants, Children, and Adolescents: 60 mg/kg/dose (0.6 mL/kg/dose of a 10% solution; Max: 3 g/dose) IV; if there is a beneficial effect, start infusion of 60 to 150 mg/kg/hour (0.6 to 1.5 mL/kg/hour) IV.
Therapeutic Drug Monitoring:
-Measure serum calcium concentrations every 4 to 6 hours during intermittent infusions and every 1 to 4 hours during continuous infusion.
-Ionized calcium concentrations are the preferred measure to determine true hypocalcemia. If total serum calcium concentrations are obtained, calcium concentrations should be adjusted if hypoalbuminemia or hyperalbuminemia is present. The corrected calcium concentration may be estimated from the following formula :
--Corrected calcium (mg/dL) = serum calcium (mg/dL) + 0.8 [4 - serum albumin (g/dL)]
Maximum Dosage Limits:
-Adults
Generally, 3 g IV as a single bolus dose.
-Geriatric
Generally, 3 g IV as a single bolus dose.
-Adolescents
Generally, 200 mg/kg/dose (Max: 3 g/dose) IV as a single bolus dose; 100 mg/kg/day elemental calcium PO for hypocalcemia.
-Children
Generally, 200 mg/kg/dose (Max: 3 g/dose) IV as a single bolus dose; 100 mg/kg/day elemental calcium PO for hypocalcemia.
-Infants
Generally, 200 mg/kg/dose IV as a single bolus dose; 100 mg/kg/day elemental calcium PO for hypocalcemia.
-Neonates
Generally, 200 mg/kg/dose IV as a single bolus dose; 100 mg/kg/day elemental calcium PO for hypocalcemia.
Patients with Hepatic Impairment Dosing
Hepatic function does not impact the availability of ionized calcium after calcium gluconate injection administration; it appears that no dosage adjustments are needed. Adjust dosage based on patient response and serum calcium concentrations.
Patients with Renal Impairment Dosing
For patients with renal impairment, initiate calcium gluconate at the lower end of the recommended dose range and monitor serum calcium concentrations every 4 hours. Adjust dosage based on patient response and serum calcium concentrations.
*non-FDA-approved indication
Abacavir; Dolutegravir; Lamivudine: (Moderate) Administer dolutegravir 2 hours before or 6 hours after taking supplements containing calcium if given under fasting conditions. When taken with food, dolutegravir and supplements containing calcium can be taken at the same time. Simultaneous administration under fasted conditions may result in reduced bioavailability of dolutegravir.
Alendronate: (Moderate) Separate administration of alendronate and calcium-containing supplements by at least 30 minutes. Calcium will interfere with the absorption of alendronate.
Alendronate; Cholecalciferol: (Moderate) Separate administration of alendronate and calcium-containing supplements by at least 30 minutes. Calcium will interfere with the absorption of alendronate.
Aliskiren; Hydrochlorothiazide, HCTZ: (Moderate) Monitor serum calcium concentration during concomitant calcium and thiazide diuretic use due to the risk for hypercalcemia. Thiazide diuretics may decrease urinary calcium excretion and cause intermittent and slight increases in serum calcium.
Amiloride; Hydrochlorothiazide, HCTZ: (Moderate) Monitor serum calcium concentration during concomitant calcium and thiazide diuretic use due to the risk for hypercalcemia. Thiazide diuretics may decrease urinary calcium excretion and cause intermittent and slight increases in serum calcium.
Amlodipine: (Minor) Monitor blood pressure during concurrent use of calcium and calcium-channel blockers. Concomitant use may reduce the response to calcium-channel blockers.
Amlodipine; Atorvastatin: (Minor) Monitor blood pressure during concurrent use of calcium and calcium-channel blockers. Concomitant use may reduce the response to calcium-channel blockers.
Amlodipine; Benazepril: (Minor) Monitor blood pressure during concurrent use of calcium and calcium-channel blockers. Concomitant use may reduce the response to calcium-channel blockers.
Amlodipine; Celecoxib: (Minor) Monitor blood pressure during concurrent use of calcium and calcium-channel blockers. Concomitant use may reduce the response to calcium-channel blockers.
Amlodipine; Olmesartan: (Minor) Monitor blood pressure during concurrent use of calcium and calcium-channel blockers. Concomitant use may reduce the response to calcium-channel blockers.
Amlodipine; Valsartan: (Minor) Monitor blood pressure during concurrent use of calcium and calcium-channel blockers. Concomitant use may reduce the response to calcium-channel blockers.
Amlodipine; Valsartan; Hydrochlorothiazide, HCTZ: (Moderate) Monitor serum calcium concentration during concomitant calcium and thiazide diuretic use due to the risk for hypercalcemia. Thiazide diuretics may decrease urinary calcium excretion and cause intermittent and slight increases in serum calcium. (Minor) Monitor blood pressure during concurrent use of calcium and calcium-channel blockers. Concomitant use may reduce the response to calcium-channel blockers.
Atenolol: (Minor) Calcium antacids (e.g., calcium carbonate) and supplements (e.g., other oral calcium salts) have been reported to reduce the mean peak concentrations by 51% and the AUC of atenolol by 32%. In another study, antacids reduced the AUC of atenolol by 33%. Separate doses of atenolol and calcium-containing antacids or supplements by at least 2 hours to minimize this potential interaction,. However, most clinicians consider the interaction of atenolol with antacids to be of minor clinical significance, since clinical efficacy (heart rate and blood pressure parameters) appear to be unchanged under usual intermittent clinical use.
Atenolol; Chlorthalidone: (Moderate) Monitor serum calcium concentration during concomitant calcium and thiazide diuretic use due to the risk for hypercalcemia. Thiazide diuretics may decrease urinary calcium excretion and cause intermittent and slight increases in serum calcium. (Minor) Calcium antacids (e.g., calcium carbonate) and supplements (e.g., other oral calcium salts) have been reported to reduce the mean peak concentrations by 51% and the AUC of atenolol by 32%. In another study, antacids reduced the AUC of atenolol by 33%. Separate doses of atenolol and calcium-containing antacids or supplements by at least 2 hours to minimize this potential interaction,. However, most clinicians consider the interaction of atenolol with antacids to be of minor clinical significance, since clinical efficacy (heart rate and blood pressure parameters) appear to be unchanged under usual intermittent clinical use.
Atracurium: (Moderate) Concomitant use of neuromuscular blockers and calcium may result in resistance to neuromuscular blockade. Calcium antagonizes the potentiating effect of magnesium on neuromuscular blockade. Also, calcium triggers acetylcholine release, and therefore, may both reduce the sensitivity to neuromuscular blockers and decrease the duration of neuromuscular blockade.
Azilsartan; Chlorthalidone: (Moderate) Monitor serum calcium concentration during concomitant calcium and thiazide diuretic use due to the risk for hypercalcemia. Thiazide diuretics may decrease urinary calcium excretion and cause intermittent and slight increases in serum calcium.
Baloxavir Marboxil: (Major) Do not administer baloxavir with products that contain calcium. Polyvalent cations, such as calcium, can chelate with baloxavir, reducing its absorption.
Benazepril; Hydrochlorothiazide, HCTZ: (Moderate) Monitor serum calcium concentration during concomitant calcium and thiazide diuretic use due to the risk for hypercalcemia. Thiazide diuretics may decrease urinary calcium excretion and cause intermittent and slight increases in serum calcium.
Bictegravir; Emtricitabine; Tenofovir Alafenamide: (Moderate) Administer bictegravir with food at the same time as oral calcium supplements. Routine administration of bictegravir under fasting conditions simultaneously with, or 2 hours after, calcium supplements is not recommended. Calcium is a polyvalent cation that can bind bictegravir in the GI tract. Taking these drugs simultaneously without food results in reduced bioavailability of bictegravir. In drug interaction studies, simultaneous administration of bictegravir with another calcium supplement under fasted conditions decreased the mean AUC of bictegravir by approximately 33%.
Bismuth Subcitrate Potassium; Metronidazole; Tetracycline: (Moderate) Divalent or trivalent cations readily chelate with tetracycline antibiotics, forming insoluble compounds. The oral absorption of these antibiotics will be significantly reduced by other orally administered compounds that contain calcium salts, particularly if the time of administration is within 60 minutes of each other. Calcium salts and tetracyclines should not be administered within 1 to 2 hours of each other, although doxycycline chelates less with calcium than other tetracyclines.
Bismuth Subsalicylate; Metronidazole; Tetracycline: (Moderate) Divalent or trivalent cations readily chelate with tetracycline antibiotics, forming insoluble compounds. The oral absorption of these antibiotics will be significantly reduced by other orally administered compounds that contain calcium salts, particularly if the time of administration is within 60 minutes of each other. Calcium salts and tetracyclines should not be administered within 1 to 2 hours of each other, although doxycycline chelates less with calcium than other tetracyclines.
Bisoprolol; Hydrochlorothiazide, HCTZ: (Moderate) Monitor serum calcium concentration during concomitant calcium and thiazide diuretic use due to the risk for hypercalcemia. Thiazide diuretics may decrease urinary calcium excretion and cause intermittent and slight increases in serum calcium.
Cabotegravir: (Moderate) Administer oral calcium at least two hours before or four hours after taking oral cabotegravir. Calcium is a polyvalent cation that can bind cabotegravir in the GI tract. Taking these drugs simultaneously may result in reduced oral bioavailability of cabotegravir.
Cabotegravir; Rilpivirine: (Moderate) Administer oral calcium at least two hours before or four hours after taking oral cabotegravir. Calcium is a polyvalent cation that can bind cabotegravir in the GI tract. Taking these drugs simultaneously may result in reduced oral bioavailability of cabotegravir.
Calcifediol: (Moderate) Monitor serum calcium concentrations during concomitant use of high doses of calcium and vitamin D analogs; a dosage adjustment of the vitamin D analog may be needed. Hypercalcemia may be exacerbated by concomitant administration.
Calcipotriene: (Minor) There is evidence that calcipotriene can be absorbed in amounts that are sufficient to produce systemic effects, including elevated serum calcium; hypercalcemia has been observed in normal prescription use. Use calcipotriene cautiously with other agents that can produce hypercalcemia (e.g., calcium salts or supplements including calcium carbonate).
Calcipotriene; Betamethasone: (Minor) There is evidence that calcipotriene can be absorbed in amounts that are sufficient to produce systemic effects, including elevated serum calcium; hypercalcemia has been observed in normal prescription use. Use calcipotriene cautiously with other agents that can produce hypercalcemia (e.g., calcium salts or supplements including calcium carbonate).
Calcitonin: (Moderate) Calcitonin is given to hypercalcemic patients to reduce serum calcium concentrations. For the treatment of hypercalcemia, calcium supplements should be avoided. Calcium salts, including calcium carbonate, can elevate serum calcium concentrations and antagonize the effects of the calcitonin for this condition. For the treatment of osteoporosis adequate intake of calcium salts are necessary in conjunction with calcitonin. An increase in serum calcium concentrations helps to reduce bone resorption and loss of bone mass, and offsets the effect of calcitonin in lowering serum calcium levels.
Calcitriol: (Moderate) Monitor serum calcium concentrations during concomitant use of high doses of calcium and vitamin D analogs; a dosage adjustment of the vitamin D analog may be needed. Hypercalcemia may be exacerbated by concomitant administration.
Calcium Phosphate, Supersaturated: (Moderate) The concomitant use of oral sodium phosphate monobasic monohydrate; sodium phosphate dibasic anhydrous preparations in conjunction with antacids containing calcium (e.g., calcium carbonate, calcium salts) may bind the phosphate in the stomach and reduce its absorption. If the patient requires multiple mineral supplements or concurrent use of antacids, it is prudent to separate the administration of sodium phosphate salts from calcium containing products by at least one hour.
Calcium-channel blockers: (Minor) Monitor blood pressure during concurrent use of calcium and calcium-channel blockers. Concomitant use may reduce the response to calcium-channel blockers.
Candesartan; Hydrochlorothiazide, HCTZ: (Moderate) Monitor serum calcium concentration during concomitant calcium and thiazide diuretic use due to the risk for hypercalcemia. Thiazide diuretics may decrease urinary calcium excretion and cause intermittent and slight increases in serum calcium.
Captopril; Hydrochlorothiazide, HCTZ: (Moderate) Monitor serum calcium concentration during concomitant calcium and thiazide diuretic use due to the risk for hypercalcemia. Thiazide diuretics may decrease urinary calcium excretion and cause intermittent and slight increases in serum calcium.
Cardiac glycosides: (Moderate) Monitor for signs and symptoms of digoxin toxicity during concomitant calcium use. Hypercalcemia may predispose persons to digoxin toxicity. If IV calcium is administered rapidly in a person receiving digoxin, serious arrhythmias may occur. Monitor ECG and calcium concentrations closely during IV calcium and digoxin administration.
Ceftriaxone: (Major) Ceftriaxone is contraindicated in neonates who are receiving or are expected to receive IV calcium-containing solutions, including calcium-containing parenteral nutrition. Cases of fatal pulmonary and renal precipitate embolism in neonates have been described. There have been no reports of an interaction between ceftriaxone and oral calcium-containing products or between intramuscular ceftriaxone and calcium-containing products. Precipitation of ceftriaxone and calcium can occur when mixed. In patients other than neonates, the risk for precipitate embolism may be adequately addressed by separating administrations or administering each medication sequentially if IV infusion lines are thoroughly flushed between infusions with a compatible fluid.
Chlorothiazide: (Moderate) Monitor serum calcium concentration during concomitant calcium and thiazide diuretic use due to the risk for hypercalcemia. Thiazide diuretics may decrease urinary calcium excretion and cause intermittent and slight increases in serum calcium.
Chlorthalidone: (Moderate) Monitor serum calcium concentration during concomitant calcium and thiazide diuretic use due to the risk for hypercalcemia. Thiazide diuretics may decrease urinary calcium excretion and cause intermittent and slight increases in serum calcium.
Ciprofloxacin: (Moderate) Administer oral ciprofloxacin at least 2 hours before or 6 hours after oral products that contain calcium. Ciprofloxacin absorption may be reduced as quinolone antibiotics can chelate with divalent or trivalent cations. Examples of compounds that may interfere with quinolone bioavailability include antacids and multivitamins that contain calcium.
Cisatracurium: (Moderate) Concomitant use of neuromuscular blockers and calcium may result in resistance to neuromuscular blockade. Calcium antagonizes the potentiating effect of magnesium on neuromuscular blockade. Also, calcium triggers acetylcholine release, and therefore, may both reduce the sensitivity to neuromuscular blockers and decrease the duration of neuromuscular blockade.
Clevidipine: (Minor) Monitor blood pressure during concurrent use of calcium and calcium-channel blockers. Concomitant use may reduce the response to calcium-channel blockers.
Cod Liver Oil: (Minor) Doses in excess of 1,500 to 2,000 mcg per day of Vitamin A may lead to bone loss and will counteract the effects of supplementation with calcium salts.
Conjugated Estrogens: (Minor) Estrogens can increase calcium absorption. Use caution in patients predisposed to hypercalcemia or nephrolithiasis.
Conjugated Estrogens; Bazedoxifene: (Minor) Estrogens can increase calcium absorption. Use caution in patients predisposed to hypercalcemia or nephrolithiasis.
Conjugated Estrogens; Medroxyprogesterone: (Minor) Estrogens can increase calcium absorption. Use caution in patients predisposed to hypercalcemia or nephrolithiasis.
Delafloxacin: (Major) Administer oral delafloxacin at least 2 hours before or 6 hours after oral products that contain calcium. Delafloxacin absorption may be reduced as quinolone antibiotics can chelate with divalent or trivalent cations. Examples of compounds that may interfere with fluoroquinolone bioavailability include antacids and multivitamins that contain calcium.
Demeclocycline: (Moderate) Divalent or trivalent cations readily chelate with tetracycline antibiotics, forming insoluble compounds. The oral absorption of these antibiotics will be significantly reduced by other orally administered compounds that contain calcium salts, particularly if the time of administration is within 60 minutes of each other. Calcium salts and tetracyclines should not be administered within 1 to 2 hours of each other, although doxycycline chelates less with calcium than other tetracyclines.
Desogestrel; Ethinyl Estradiol: (Minor) Estrogens can increase calcium absorption. Use caution in patients predisposed to hypercalcemia or nephrolithiasis.
Dienogest; Estradiol valerate: (Minor) Estrogens can increase calcium absorption. Use caution in patients predisposed to hypercalcemia or nephrolithiasis.
Digoxin: (Moderate) Monitor for signs and symptoms of digoxin toxicity during concomitant calcium use. Hypercalcemia may predispose persons to digoxin toxicity. If IV calcium is administered rapidly in a person receiving digoxin, serious arrhythmias may occur. Monitor ECG and calcium concentrations closely during IV calcium and digoxin administration.
Diltiazem: (Minor) Monitor blood pressure during concurrent use of calcium and calcium-channel blockers. Concomitant use may reduce the response to calcium-channel blockers.
Dolutegravir: (Moderate) Administer dolutegravir 2 hours before or 6 hours after taking supplements containing calcium if given under fasting conditions. When taken with food, dolutegravir and supplements containing calcium can be taken at the same time. Simultaneous administration under fasted conditions may result in reduced bioavailability of dolutegravir.
Dolutegravir; Lamivudine: (Moderate) Administer dolutegravir 2 hours before or 6 hours after taking supplements containing calcium if given under fasting conditions. When taken with food, dolutegravir and supplements containing calcium can be taken at the same time. Simultaneous administration under fasted conditions may result in reduced bioavailability of dolutegravir.
Dolutegravir; Rilpivirine: (Moderate) Administer dolutegravir 2 hours before or 6 hours after taking supplements containing calcium if given under fasting conditions. When taken with food, dolutegravir and supplements containing calcium can be taken at the same time. Simultaneous administration under fasted conditions may result in reduced bioavailability of dolutegravir.
Doxercalciferol: (Moderate) Monitor serum calcium concentrations during concomitant use of high doses of calcium and vitamin D analogs; a dosage adjustment of the vitamin D analog may be needed. Hypercalcemia may be exacerbated by concomitant administration.
Doxycycline: (Moderate) Divalent or trivalent cations readily chelate with tetracycline antibiotics, forming insoluble compounds. The oral absorption of these antibiotics will be significantly reduced by other orally administered compounds that contain calcium salts, particularly if the time of administration is within 60 minutes of each other. Calcium salts and tetracyclines should not be administered within 1 to 2 hours of each other, although doxycycline chelates less with calcium than other tetracyclines.
Drospirenone; Estetrol: (Minor) Estrogens can increase calcium absorption. Use caution in patients predisposed to hypercalcemia or nephrolithiasis.
Drospirenone; Estradiol: (Minor) Estrogens can increase calcium absorption. Use caution in patients predisposed to hypercalcemia or nephrolithiasis.
Drospirenone; Ethinyl Estradiol: (Minor) Estrogens can increase calcium absorption. Use caution in patients predisposed to hypercalcemia or nephrolithiasis.
Drospirenone; Ethinyl Estradiol; Levomefolate: (Minor) Estrogens can increase calcium absorption. Use caution in patients predisposed to hypercalcemia or nephrolithiasis.
Edetate Calcium Disodium, Calcium EDTA: (Major) Because edetate disodium chelates and lowers serum calcium, oral or parenteral calcium salts should not be administered concomitantly.
Elagolix; Estradiol; Norethindrone acetate: (Minor) Estrogens can increase calcium absorption. Use caution in patients predisposed to hypercalcemia or nephrolithiasis.
Eltrombopag: (Major) Eltrombopag chelates polyvalent cations (e.g., calcium, aluminum, and magnesium) in food, mineral supplements, and antacids. In a clinical study, systemic exposure to eltrombopag was decreased by 70% when it was administered with a polyvalent cation-containing antacid. Administer eltrombopag at least 2 hours before or 4 hours after any oral products containing polyvalent cations, such as aluminum salts, (like aluminum hydroxide), calcium salts, (including calcium carbonate), and magnesium salts.
Elvitegravir; Cobicistat; Emtricitabine; Tenofovir Alafenamide: (Moderate) Separate administration of elvitegravir and calcium by at least 2 hours. Due to the formation of ionic complexes in the gastrointestinal tract, simultaneous administration results in lower elvitegravir plasma concentrations.
Elvitegravir; Cobicistat; Emtricitabine; Tenofovir Disoproxil Fumarate: (Moderate) Separate administration of elvitegravir and calcium by at least 2 hours. Due to the formation of ionic complexes in the gastrointestinal tract, simultaneous administration results in lower elvitegravir plasma concentrations.
Enalapril; Hydrochlorothiazide, HCTZ: (Moderate) Monitor serum calcium concentration during concomitant calcium and thiazide diuretic use due to the risk for hypercalcemia. Thiazide diuretics may decrease urinary calcium excretion and cause intermittent and slight increases in serum calcium.
Eprosartan; Hydrochlorothiazide, HCTZ: (Moderate) Monitor serum calcium concentration during concomitant calcium and thiazide diuretic use due to the risk for hypercalcemia. Thiazide diuretics may decrease urinary calcium excretion and cause intermittent and slight increases in serum calcium.
Esterified Estrogens: (Minor) Estrogens can increase calcium absorption. Use caution in patients predisposed to hypercalcemia or nephrolithiasis.
Esterified Estrogens; Methyltestosterone: (Minor) Estrogens can increase calcium absorption. Use caution in patients predisposed to hypercalcemia or nephrolithiasis.
Estradiol: (Minor) Estrogens can increase calcium absorption. Use caution in patients predisposed to hypercalcemia or nephrolithiasis.
Estradiol; Levonorgestrel: (Minor) Estrogens can increase calcium absorption. Use caution in patients predisposed to hypercalcemia or nephrolithiasis.
Estradiol; Norethindrone: (Minor) Estrogens can increase calcium absorption. Use caution in patients predisposed to hypercalcemia or nephrolithiasis.
Estradiol; Norgestimate: (Minor) Estrogens can increase calcium absorption. Use caution in patients predisposed to hypercalcemia or nephrolithiasis.
Estradiol; Progesterone: (Minor) Estrogens can increase calcium absorption. Use caution in patients predisposed to hypercalcemia or nephrolithiasis.
Estramustine: (Major) Administration of estramustine with calcium impairs the oral absorption of estramustine significantly, due to formation of a calcium-phosphate complex. Calcium-containing drugs must not be taken simultaneously with estramustine. Patients should be instructed to take estramustine with water at least 1 hour before or 2 hours after calcium supplements.
Estrogens: (Minor) Estrogens can increase calcium absorption. Use caution in patients predisposed to hypercalcemia or nephrolithiasis.
Estropipate: (Minor) Estrogens can increase calcium absorption. Use caution in patients predisposed to hypercalcemia or nephrolithiasis.
Ethinyl Estradiol; Norelgestromin: (Minor) Estrogens can increase calcium absorption. Use caution in patients predisposed to hypercalcemia or nephrolithiasis.
Ethinyl Estradiol; Norethindrone Acetate: (Minor) Estrogens can increase calcium absorption. Use caution in patients predisposed to hypercalcemia or nephrolithiasis.
Ethinyl Estradiol; Norgestrel: (Minor) Estrogens can increase calcium absorption. Use caution in patients predisposed to hypercalcemia or nephrolithiasis.
Ethotoin: (Major) Oral absorption of phenytoin can be reduced by calcium salts. Calcium salts can form complexes that are nonabsorbable. Separating the administration of phenytoin and calcium salts by at least 2 hours to help avoid this interaction. A similar interaction may occur with ethotoin.
Ethynodiol Diacetate; Ethinyl Estradiol: (Minor) Estrogens can increase calcium absorption. Use caution in patients predisposed to hypercalcemia or nephrolithiasis.
Etidronate: (Moderate) Separate administration of oral etidronate and calcium-containing supplements by at least 2 hours. Calcium will interfere with the absorption of oral etidronate.
Etonogestrel; Ethinyl Estradiol: (Minor) Estrogens can increase calcium absorption. Use caution in patients predisposed to hypercalcemia or nephrolithiasis.
Felodipine: (Minor) Monitor blood pressure during concurrent use of calcium and calcium-channel blockers. Concomitant use may reduce the response to calcium-channel blockers.
Fosinopril; Hydrochlorothiazide, HCTZ: (Moderate) Monitor serum calcium concentration during concomitant calcium and thiazide diuretic use due to the risk for hypercalcemia. Thiazide diuretics may decrease urinary calcium excretion and cause intermittent and slight increases in serum calcium.
Hydrochlorothiazide, HCTZ: (Moderate) Monitor serum calcium concentration during concomitant calcium and thiazide diuretic use due to the risk for hypercalcemia. Thiazide diuretics may decrease urinary calcium excretion and cause intermittent and slight increases in serum calcium.
Hydrochlorothiazide, HCTZ; Moexipril: (Moderate) Monitor serum calcium concentration during concomitant calcium and thiazide diuretic use due to the risk for hypercalcemia. Thiazide diuretics may decrease urinary calcium excretion and cause intermittent and slight increases in serum calcium.
Ibandronate: (Moderate) Separate administration of oral ibandronate and calcium-containing supplements by at least 1 hour. Calcium will interfere with the absorption of oral ibandronate.
Ibritumomab Tiuxetan: (Moderate) The oral absorption of phosphorus is reduced by ingestion of pharmacologic doses of calcium carbonate or other phosphate-lowering calcium salts (e.g., calcium acetate). There is, however, no significant interference with phosphorus absorption by oral dietary calcium at intakes within the typical adult range. If the patient requires multiple calcium supplements or a calcium-containing antacid, it may be wise to separate the administration of phosphorus salts from calcium-containing products. In some instances the administration of calcium salts or calcium carbonate is used therapeutically (e.g., uremia) to decrease serum phosphorus levels, so the administration of phosphorus supplements would dynamically counteract the intended use of calcium in these settings, assuming hypophosphatemia is not present. Appropriate calcium-phosphorus ratios in vivo are important for proper calcium homeostasis in tissues and bone; if the serum ionized calcium concentration is elevated, the concomitant use of calcium salts and phosphorus salts may increase the risk of calcium deposition in soft tissue.
Irbesartan; Hydrochlorothiazide, HCTZ: (Moderate) Monitor serum calcium concentration during concomitant calcium and thiazide diuretic use due to the risk for hypercalcemia. Thiazide diuretics may decrease urinary calcium excretion and cause intermittent and slight increases in serum calcium.
Isradipine: (Minor) Monitor blood pressure during concurrent use of calcium and calcium-channel blockers. Concomitant use may reduce the response to calcium-channel blockers.
Levamlodipine: (Minor) Monitor blood pressure during concurrent use of calcium and calcium-channel blockers. Concomitant use may reduce the response to calcium-channel blockers.
Levofloxacin: (Moderate) Administer oral products that contain calcium at least 2 hours before or 2 hours after orally administered levofloxacin. Levofloxacin absorption may be reduced as quinolone antibiotics can chelate with divalent or trivalent cations. Chelation of divalent cations with levofloxacin is less than with other quinolones. Examples of compounds that may interfere with quinolone bioavailability include antacids and multivitamins that contain calcium.
Levonorgestrel; Ethinyl Estradiol: (Minor) Estrogens can increase calcium absorption. Use caution in patients predisposed to hypercalcemia or nephrolithiasis.
Levonorgestrel; Ethinyl Estradiol; Ferrous Bisglycinate: (Minor) Estrogens can increase calcium absorption. Use caution in patients predisposed to hypercalcemia or nephrolithiasis.
Levonorgestrel; Ethinyl Estradiol; Ferrous Fumarate: (Minor) Estrogens can increase calcium absorption. Use caution in patients predisposed to hypercalcemia or nephrolithiasis.
Levothyroxine: (Moderate) Thyroid hormones should be administered at least 4 hours before or after the ingestion of oral calcium supplements. Calcium salts have been reported to chelate oral thyroid hormones within the GI tract when administered simultaneously, leading to decreased thyroid hormone absorption. Some case reports have described clinical hypothyroidism resulting from coadministration of thyroid hormones with oral calcium supplements.
Levothyroxine; Liothyronine (Porcine): (Moderate) Thyroid hormones should be administered at least 4 hours before or after the ingestion of oral calcium supplements. Calcium salts have been reported to chelate oral thyroid hormones within the GI tract when administered simultaneously, leading to decreased thyroid hormone absorption. Some case reports have described clinical hypothyroidism resulting from coadministration of thyroid hormones with oral calcium supplements.
Levothyroxine; Liothyronine (Synthetic): (Moderate) Thyroid hormones should be administered at least 4 hours before or after the ingestion of oral calcium supplements. Calcium salts have been reported to chelate oral thyroid hormones within the GI tract when administered simultaneously, leading to decreased thyroid hormone absorption. Some case reports have described clinical hypothyroidism resulting from coadministration of thyroid hormones with oral calcium supplements.
Liothyronine: (Moderate) Thyroid hormones should be administered at least 4 hours before or after the ingestion of oral calcium supplements. Calcium salts have been reported to chelate oral thyroid hormones within the GI tract when administered simultaneously, leading to decreased thyroid hormone absorption. Some case reports have described clinical hypothyroidism resulting from coadministration of thyroid hormones with oral calcium supplements.
Lisinopril; Hydrochlorothiazide, HCTZ: (Moderate) Monitor serum calcium concentration during concomitant calcium and thiazide diuretic use due to the risk for hypercalcemia. Thiazide diuretics may decrease urinary calcium excretion and cause intermittent and slight increases in serum calcium.
Lithium: (Moderate) Monitor serum calcium concentrations closely if concomitant use of calcium and lithium is necessary. Concomitant use may increase the risk of hypercalcemia.
Losartan; Hydrochlorothiazide, HCTZ: (Moderate) Monitor serum calcium concentration during concomitant calcium and thiazide diuretic use due to the risk for hypercalcemia. Thiazide diuretics may decrease urinary calcium excretion and cause intermittent and slight increases in serum calcium.
Metolazone: (Moderate) Monitor serum calcium concentration during concomitant calcium and thiazide diuretic use due to the risk for hypercalcemia. Thiazide diuretics may decrease urinary calcium excretion and cause intermittent and slight increases in serum calcium.
Metoprolol; Hydrochlorothiazide, HCTZ: (Moderate) Monitor serum calcium concentration during concomitant calcium and thiazide diuretic use due to the risk for hypercalcemia. Thiazide diuretics may decrease urinary calcium excretion and cause intermittent and slight increases in serum calcium.
Minocycline: (Moderate) Divalent or trivalent cations readily chelate with tetracycline antibiotics, forming insoluble compounds. The oral absorption of these antibiotics will be significantly reduced by other orally administered compounds that contain calcium salts, particularly if the time of administration is within 60 minutes of each other. Calcium salts and tetracyclines should not be administered within 1 to 2 hours of each other, although doxycycline chelates less with calcium than other tetracyclines.
Moxifloxacin: (Major) Administer oral moxifloxacin at least 4 hours before or 8 hours after oral products that contain calcium. Moxifloxacin absorption may be reduced as quinolone antibiotics can chelate with divalent or trivalent cations. Examples of compounds that may interfere with quinolone bioavailability include antacids and multivitamins that contain calcium.
Neuromuscular blockers: (Moderate) Concomitant use of neuromuscular blockers and calcium may result in resistance to neuromuscular blockade. Calcium antagonizes the potentiating effect of magnesium on neuromuscular blockade. Also, calcium triggers acetylcholine release, and therefore, may both reduce the sensitivity to neuromuscular blockers and decrease the duration of neuromuscular blockade.
Nicardipine: (Minor) Monitor blood pressure during concurrent use of calcium and calcium-channel blockers. Concomitant use may reduce the response to calcium-channel blockers.
NIFEdipine: (Minor) Monitor blood pressure during concurrent use of calcium and calcium-channel blockers. Concomitant use may reduce the response to calcium-channel blockers.
Nimodipine: (Minor) Monitor blood pressure during concurrent use of calcium and calcium-channel blockers. Concomitant use may reduce the response to calcium-channel blockers.
Nisoldipine: (Minor) Monitor blood pressure during concurrent use of calcium and calcium-channel blockers. Concomitant use may reduce the response to calcium-channel blockers.
Norethindrone Acetate; Ethinyl Estradiol; Ferrous fumarate: (Minor) Estrogens can increase calcium absorption. Use caution in patients predisposed to hypercalcemia or nephrolithiasis.
Norethindrone; Ethinyl Estradiol: (Minor) Estrogens can increase calcium absorption. Use caution in patients predisposed to hypercalcemia or nephrolithiasis.
Norethindrone; Ethinyl Estradiol; Ferrous fumarate: (Minor) Estrogens can increase calcium absorption. Use caution in patients predisposed to hypercalcemia or nephrolithiasis.
Norgestimate; Ethinyl Estradiol: (Minor) Estrogens can increase calcium absorption. Use caution in patients predisposed to hypercalcemia or nephrolithiasis.
Ofloxacin: (Moderate) Administer oral products that contain calcium at least 2 hours before or 2 hours after ofloxacin. Ofloxacin absorption may be reduced as quinolone antibiotics can chelate with divalent or trivalent cations. Examples of compounds that may interfere with quinolone bioavailability include antacids and multivitamins that contain calcium.
Olmesartan; Amlodipine; Hydrochlorothiazide, HCTZ: (Moderate) Monitor serum calcium concentration during concomitant calcium and thiazide diuretic use due to the risk for hypercalcemia. Thiazide diuretics may decrease urinary calcium excretion and cause intermittent and slight increases in serum calcium. (Minor) Monitor blood pressure during concurrent use of calcium and calcium-channel blockers. Concomitant use may reduce the response to calcium-channel blockers.
Olmesartan; Hydrochlorothiazide, HCTZ: (Moderate) Monitor serum calcium concentration during concomitant calcium and thiazide diuretic use due to the risk for hypercalcemia. Thiazide diuretics may decrease urinary calcium excretion and cause intermittent and slight increases in serum calcium.
Omadacycline: (Moderate) Divalent or trivalent cations readily chelate with tetracycline antibiotics, forming insoluble compounds. The oral absorption of these antibiotics will be significantly reduced by other orally administered compounds that contain calcium salts, particularly if the time of administration is within 60 minutes of each other. Calcium salts and tetracyclines should not be administered within 1 to 2 hours of each other, although doxycycline chelates less with calcium than other tetracyclines.
Pancuronium: (Moderate) Concomitant use of neuromuscular blockers and calcium may result in resistance to neuromuscular blockade. Calcium antagonizes the potentiating effect of magnesium on neuromuscular blockade. Also, calcium triggers acetylcholine release, and therefore, may both reduce the sensitivity to neuromuscular blockers and decrease the duration of neuromuscular blockade.
Parathyroid Hormone: (Moderate) Monitor serum calcium concentrations closely if concomitant use of calcium and parathyroid hormone is necessary. Concomitant use may increase the risk of hypercalcemia.
Paricalcitol: (Moderate) Monitor serum calcium concentrations during concomitant use of high doses of calcium and vitamin D analogs; a dosage adjustment of the vitamin D analog may be needed. Hypercalcemia may be exacerbated by concomitant administration.
Perindopril; Amlodipine: (Minor) Monitor blood pressure during concurrent use of calcium and calcium-channel blockers. Concomitant use may reduce the response to calcium-channel blockers.
Phenytoin: (Moderate) Oral absorption of phenytoin can be reduced by calcium salts. Calcium salts can form complexes that are nonabsorbable. Separating the administration of phenytoin and calcium salts by at least 2 hours will help avoid this interaction. A similar interaction may occur with ethotoin.
Phosphorated Carbohydrate Solution: (Moderate) The oral absorption of phosphorus is reduced by ingestion of pharmacologic doses of calcium carbonate or other phosphate-lowering calcium salts (e.g., calcium acetate). There is, however, no significant interference with phosphorus absorption by oral dietary calcium at intakes within the typical adult range. If the patient requires multiple calcium supplements or a calcium-containing antacid, it may be wise to separate the administration of phosphorus salts from calcium-containing products. In some instances the administration of calcium salts or calcium carbonate is used therapeutically (e.g., uremia) to decrease serum phosphorus levels, so the administration of phosphorus supplements would dynamically counteract the intended use of calcium in these settings, assuming hypophosphatemia is not present. Appropriate calcium-phosphorus ratios in vivo are important for proper calcium homeostasis in tissues and bone; if the serum ionized calcium concentration is elevated, the concomitant use of calcium salts and phosphorus salts may increase the risk of calcium deposition in soft tissue.
Phosphorus: (Moderate) The oral absorption of phosphorus is reduced by ingestion of pharmacologic doses of calcium carbonate or other phosphate-lowering calcium salts (e.g., calcium acetate). There is, however, no significant interference with phosphorus absorption by oral dietary calcium at intakes within the typical adult range. If the patient requires multiple calcium supplements or a calcium-containing antacid, it may be wise to separate the administration of phosphorus salts from calcium-containing products. In some instances the administration of calcium salts or calcium carbonate is used therapeutically (e.g., uremia) to decrease serum phosphorus levels, so the administration of phosphorus supplements would dynamically counteract the intended use of calcium in these settings, assuming hypophosphatemia is not present. Appropriate calcium-phosphorus ratios in vivo are important for proper calcium homeostasis in tissues and bone; if the serum ionized calcium concentration is elevated, the concomitant use of calcium salts and phosphorus salts may increase the risk of calcium deposition in soft tissue.
Potassium Phosphate: (Moderate) The oral absorption of phosphorus is reduced by ingestion of pharmacologic doses of calcium carbonate or other phosphate-lowering calcium salts (e.g., calcium acetate). There is, however, no significant interference with phosphorus absorption by oral dietary calcium at intakes within the typical adult range. If the patient requires multiple calcium supplements or a calcium-containing antacid, it may be wise to separate the administration of phosphorus salts from calcium-containing products. In some instances the administration of calcium salts or calcium carbonate is used therapeutically (e.g., uremia) to decrease serum phosphorus levels, so the administration of phosphorus supplements would dynamically counteract the intended use of calcium in these settings, assuming hypophosphatemia is not present. Appropriate calcium-phosphorus ratios in vivo are important for proper calcium homeostasis in tissues and bone; if the serum ionized calcium concentration is elevated, the concomitant use of calcium salts and phosphorus salts may increase the risk of calcium deposition in soft tissue.
Potassium Phosphate; Sodium Phosphate: (Moderate) The oral absorption of phosphorus is reduced by ingestion of pharmacologic doses of calcium carbonate or other phosphate-lowering calcium salts (e.g., calcium acetate). There is, however, no significant interference with phosphorus absorption by oral dietary calcium at intakes within the typical adult range. If the patient requires multiple calcium supplements or a calcium-containing antacid, it may be wise to separate the administration of phosphorus salts from calcium-containing products. In some instances the administration of calcium salts or calcium carbonate is used therapeutically (e.g., uremia) to decrease serum phosphorus levels, so the administration of phosphorus supplements would dynamically counteract the intended use of calcium in these settings, assuming hypophosphatemia is not present. Appropriate calcium-phosphorus ratios in vivo are important for proper calcium homeostasis in tissues and bone; if the serum ionized calcium concentration is elevated, the concomitant use of calcium salts and phosphorus salts may increase the risk of calcium deposition in soft tissue.
Quinapril; Hydrochlorothiazide, HCTZ: (Moderate) Monitor serum calcium concentration during concomitant calcium and thiazide diuretic use due to the risk for hypercalcemia. Thiazide diuretics may decrease urinary calcium excretion and cause intermittent and slight increases in serum calcium.
Relugolix; Estradiol; Norethindrone acetate: (Minor) Estrogens can increase calcium absorption. Use caution in patients predisposed to hypercalcemia or nephrolithiasis.
Risedronate: (Moderate) Separate administration of oral risedronate and calcium-containing supplements by at least 2 hours. Calcium will interfere with the absorption of oral risedronate.
Rocuronium: (Moderate) Concomitant use of neuromuscular blockers and calcium may result in resistance to neuromuscular blockade. Calcium antagonizes the potentiating effect of magnesium on neuromuscular blockade. Also, calcium triggers acetylcholine release, and therefore, may both reduce the sensitivity to neuromuscular blockers and decrease the duration of neuromuscular blockade.
Sarecycline: (Moderate) Divalent or trivalent cations readily chelate with tetracycline antibiotics, forming insoluble compounds. The oral absorption of these antibiotics will be significantly reduced by other orally administered compounds that contain calcium salts, particularly if the time of administration is within 60 minutes of each other. Calcium salts and tetracyclines should not be administered within 1 to 2 hours of each other, although doxycycline chelates less with calcium than other tetracyclines.
Segesterone Acetate; Ethinyl Estradiol: (Minor) Estrogens can increase calcium absorption. Use caution in patients predisposed to hypercalcemia or nephrolithiasis.
Sodium Fluoride: (Moderate) Absorption of sodium fluoride may be reduced by concomitant use of antacids that contain magnesium, aluminum, or calcium. An interval of at least 2 hours is advisable between administration of sodium fluoride and antacids.
Sodium Phosphate Monobasic Monohydrate; Sodium Phosphate Dibasic Anhydrous: (Moderate) The concomitant use of oral sodium phosphate monobasic monohydrate; sodium phosphate dibasic anhydrous preparations in conjunction with antacids containing calcium (e.g., calcium carbonate, calcium salts) may bind the phosphate in the stomach and reduce its absorption. If the patient requires multiple mineral supplements or concurrent use of antacids, it is prudent to separate the administration of sodium phosphate salts from calcium containing products by at least one hour.
Spironolactone; Hydrochlorothiazide, HCTZ: (Moderate) Monitor serum calcium concentration during concomitant calcium and thiazide diuretic use due to the risk for hypercalcemia. Thiazide diuretics may decrease urinary calcium excretion and cause intermittent and slight increases in serum calcium.
Succinylcholine: (Moderate) Concomitant use of neuromuscular blockers and calcium may result in resistance to neuromuscular blockade. Calcium antagonizes the potentiating effect of magnesium on neuromuscular blockade. Also, calcium triggers acetylcholine release, and therefore, may both reduce the sensitivity to neuromuscular blockers and decrease the duration of neuromuscular blockade.
Sucralfate: (Moderate) Oral antacids, including calcium salts, potentially interfere with gastric mucosal binding of sucralfate. This interaction can be minimized by staggering the doses of these agents as much as possible.
Sulfacetamide; Sulfur: (Major) Because edetate disodium chelates and lowers serum calcium, oral or parenteral calcium salts should not be administered concomitantly.
Telmisartan; Amlodipine: (Minor) Monitor blood pressure during concurrent use of calcium and calcium-channel blockers. Concomitant use may reduce the response to calcium-channel blockers.
Telmisartan; Hydrochlorothiazide, HCTZ: (Moderate) Monitor serum calcium concentration during concomitant calcium and thiazide diuretic use due to the risk for hypercalcemia. Thiazide diuretics may decrease urinary calcium excretion and cause intermittent and slight increases in serum calcium.
Teriparatide: (Moderate) Monitor serum calcium concentrations closely if concomitant use of calcium and teriparatide is necessary. Concomitant use may increase the risk of hypercalcemia.
Tetracycline: (Moderate) Divalent or trivalent cations readily chelate with tetracycline antibiotics, forming insoluble compounds. The oral absorption of these antibiotics will be significantly reduced by other orally administered compounds that contain calcium salts, particularly if the time of administration is within 60 minutes of each other. Calcium salts and tetracyclines should not be administered within 1 to 2 hours of each other, although doxycycline chelates less with calcium than other tetracyclines.
Tetracyclines: (Moderate) Divalent or trivalent cations readily chelate with tetracycline antibiotics, forming insoluble compounds. The oral absorption of these antibiotics will be significantly reduced by other orally administered compounds that contain calcium salts, particularly if the time of administration is within 60 minutes of each other. Calcium salts and tetracyclines should not be administered within 1 to 2 hours of each other, although doxycycline chelates less with calcium than other tetracyclines.
Thiazide diuretics: (Moderate) Monitor serum calcium concentration during concomitant calcium and thiazide diuretic use due to the risk for hypercalcemia. Thiazide diuretics may decrease urinary calcium excretion and cause intermittent and slight increases in serum calcium.
Thyroid hormones: (Moderate) Thyroid hormones should be administered at least 4 hours before or after the ingestion of oral calcium supplements. Calcium salts have been reported to chelate oral thyroid hormones within the GI tract when administered simultaneously, leading to decreased thyroid hormone absorption. Some case reports have described clinical hypothyroidism resulting from coadministration of thyroid hormones with oral calcium supplements.
Trandolapril; Verapamil: (Minor) Monitor blood pressure during concurrent use of calcium and calcium-channel blockers. Concomitant use may reduce the response to calcium-channel blockers.
Triamterene; Hydrochlorothiazide, HCTZ: (Moderate) Monitor serum calcium concentration during concomitant calcium and thiazide diuretic use due to the risk for hypercalcemia. Thiazide diuretics may decrease urinary calcium excretion and cause intermittent and slight increases in serum calcium.
Trientine: (Major) In general, oral mineral supplements should not be given since they may block the oral absorption of trientine. However, iron deficiency may develop, especially in children and menstruating or pregnant women, or as a result of the low copper diet recommended for Wilson's disease. If necessary, iron may be given in short courses, but since iron and trientine each inhibit oral absorption of the other, 2 hours should elapse between administration of trientine and iron doses.
Valsartan; Hydrochlorothiazide, HCTZ: (Moderate) Monitor serum calcium concentration during concomitant calcium and thiazide diuretic use due to the risk for hypercalcemia. Thiazide diuretics may decrease urinary calcium excretion and cause intermittent and slight increases in serum calcium.
Vecuronium: (Moderate) Concomitant use of neuromuscular blockers and calcium may result in resistance to neuromuscular blockade. Calcium antagonizes the potentiating effect of magnesium on neuromuscular blockade. Also, calcium triggers acetylcholine release, and therefore, may both reduce the sensitivity to neuromuscular blockers and decrease the duration of neuromuscular blockade.
Verapamil: (Minor) Monitor blood pressure during concurrent use of calcium and calcium-channel blockers. Concomitant use may reduce the response to calcium-channel blockers.
Vitamin A: (Minor) Doses in excess of 1,500 to 2,000 mcg per day of Vitamin A may lead to bone loss and will counteract the effects of supplementation with calcium salts.
Vitamin D analogs: (Moderate) Monitor serum calcium concentrations during concomitant use of high doses of calcium and vitamin D analogs; a dosage adjustment of the vitamin D analog may be needed. Hypercalcemia may be exacerbated by concomitant administration.
Calcium is the primary component of skeletal tissue, providing structural integrity and support for individual growth. Bone undergoes constant remodeling and turnover. Mineral release during the process of bone resorption buffers hydrogen ions, whereas the formation of bone generates hydrogen ions. Thus, bone serves as a calcium depot and as a reservoir for electrolytes and buffers. Inhibition of bone resorption is primarily the function of the hormone, calcitonin. The control of plasma calcium concentration is primarily maintained by parathyroid hormone, thyroxine, and 1,25 dihydroxycholecalciferol. Ionized calcium is the physiologically active form. Basic metabolic functions involve the cardiac, neuromuscular, structural, and blood coagulation systems.
Calcium gluconate is administered orally, intravenously, or intraosseously. Calcium is required by all body tissues. Approximately 98% of the body's calcium is stored in the bone, primarily as the hydroxyapatite. Constant bone remodeling and turnover of the skeleton release calcium into the systemic circulation which is then re-accumulated by the bone on a daily basis. Calcium is 40% bound to plasma proteins, primarily albumin, and 10% is in a chelated form. Approximately 50% of serum calcium is ionized, which is considered the physiologically active form. The ultrafiltratable calcium (nonprotein-bound) is distributed to the protein-poor regions of the body, such as the cerebrospinal and extracellular fluids. Calcium is primarily excreted in the feces and bile (80%). Urinary excretion accounts for the remainder (20%). However, approximately 99% of filtered calcium is reabsorbed by the kidney with less than 1% excreted. Parathyroid hormone, calcitonin, and 1,25 dihydroxycholecalciferol are primarily responsible for controlling calcium equilibrium. Insulin, thyroxine, growth hormone, androgens, estrogens, adrenal corticosteroids, and inorganic phosphate also contribute.
Affected cytochrome P450 isoenzymes: none