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CALCIUM SALTS, CALCIUM GLUCONATE, CALCIUM GLUCEPTATE, CALCIUM CHLORIDE, CALCIUM LACTATE

Chemistry - Several different salts of calcium are available in various formulations. Calciumgluceptate and calcium chloride are freely soluble in water; calcium lactate is soluble in water;calcium gluconate and calcium glycerophosphate are sparingly soluble in water, and calciumphosphate and carbonate are insoluble in water. Calcium gluconate for injection has a pH of 6-8.2;calcium chloride for injection has a pH of 5.5-7.5; and calcium gluceptate for injection has a pH of5.6-7.

Storage, Stability, Compatibility

Calcium gluconate tablets should be stored in well-closedcontainers at room temperature. Calcium lactate tablets should be stored in tight containers at roomtemperature. Calcium gluconate injection, calcium gluceptate injection, and calcium chlorideinjection should be stored at room temperature and protected from freezing.
Calcium chloride for injection is reportedly compatible with the following intravenous solutions and drugs: amikacin sulfate, ascorbic acid, bretylium tosylate, cephapirin sodium, chloramphenicol sodium succinate, dopamine HCl, hydrocortisone sodium succinate, isoproterenol HCl, lidocaine HCl, methicillin sodium, norepinephrine bitartrate, penicillin G potassium/sodium, pentobarbital sodium, phenobarbital sodium, sodium bicarbonate, verapamil HCl, and vitamin B-complex with C.
Calcium chloride for injection compatibility information conflicts or is dependent on diluentor concentration factors with the following drugs or solutions: fat emulsion 10%, dobutamine HCl, oxytetracycline HCl, and tetracycline HCl. Compatibility is dependent upon factors such as pH, concentration, temperature and diluents used. It is suggested to consult specialized references (e.g.,
Handbook on Injectable Drugs by Trissel; see bibliography) for more specific information.
Calcium chloride for injection is reportedly incompatible with the following solutions or drugs:amphotericin B, cephalothin sodium, and chlorpheniramine maleate.
Calcium gluceptate for injection is reportedly compatible with the following intravenous solutions and drugs: sodium chloride for injection 0.45% and 0.9%, Ringer's injection, lactated
Ringer's injection, dextrose 2.5%-10%, dextrose-Ringer's injection, dextrose-lactated Ringer'sinjection, dextrose-saline combinations, ascorbic acid injection, isoproterenol HCl, lidocaine HCl, norepinephrine bitartrate, phytonadione, and sodium bicarbonate.
Calcium gluceptate for injection is reportedly incompatible with the following solutions ordrugs: cefamandole naftate, cephalothin sodium, magnesium sulfate, prednisolone sodium succinate, and prochlorperazine edisylate. Compatibility is dependent upon factors such as pH, concentration, temperature and diluents used. It is suggested to consult specialized references (e.g., Handbook on
Injectable Drugs by Trissel; see bibliography) for more specific information.
Calcium gluconate for injection is reportedly compatible with the following intravenous solutions and drugs: sodium chloride for injection 0.9%, lactated Ringer's injection, dextrose 5%-20%, dextrose-lactated Ringer's injection, dextrose-saline combinations, amikacin sulfate, aminophylline, ascorbic acid injection, bretylium tosylate, cephapirin sodium, chloramphenicol sodium succinate, corticotropin, dimenhydrinate, erythromycin gluceptate, heparin sodium, hydrocortisone sodiumsuccinate, lidocaine HCl, methicillin sodium, norepinephrine bitartrate, penicillin Gpotassium/sodium, phenobarbital sodium, potassium chloride, tobramycin sulfate, vancomycin HCl, verapamil and vitamin B-complex with C.
Calcium gluconate compatibility information conflicts or is dependent on diluent or concentration factors with the following drugs or solutions: phosphate salts, oxytetracycline HCl, prochlorperazine edisylate, and tetracycline HCl. Compatibility is dependent upon factors such aspH, concentration, temperature and diluents used. It is suggested to consult specialized references(e.g., Handbook on Injectable Drugs by Trissel; see bibliography) for more specific information.
Calcium gluconate is reportedly incompatible with the following solutions or drugs: intravenousfat emulsion, amphotericin B, cefamandole naftate, cephalothin sodium, dobutamine HCl, methylprednisolone sodium succinate, and metoclopramide HCl.

Pharmacology - CALCIUM SALTS, CALCIUM GLUCONATE, CALCIUM GLUCEPTATE, CALCIUM CHLORIDE, CALCIUM LACTATE

Calcium is an essential element that is required for many functions within thebody, including proper nervous and musculoskeletal system function, cell-membrane and capillarypermeability, and activation of enzymatic reactions.

Uses, Indications

Calcium salts are used for the prevention or treatment of hypocalcemic conditions.

Pharmacokinetics - CALCIUM SALTS, CALCIUM GLUCONATE, CALCIUM GLUCEPTATE, CALCIUM CHLORIDE, CALCIUM LACTATE

Calcium is absorbed in the small intestine in the ionized form only. Presenceof vitamin D (in active form) and an acidic pH is necessary for oral absorption. Parathormone(parathyroid hormone) increases with resultant increased calcium absorption in calcium deficiencystates and decreases as serum calcium levels rise. Dietary factors (high fiber, phytates, fatty acids), age, drugs (corticosteroids, tetracyclines), disease states (steatorrhea, uremia, renal osteodystrophy, achlorhydria), or decreased serum calcitonin levels may all cause reduced amounts of calcium to beabsorbed.
After absorption, ionized calcium enters the extracellular fluid and then is rapidly incorporated intoskeletal tissue. Calcium administration does not necessarily stimulate bone formation.
Approximately 99% of total body calcium is found in bone. Of circulating calcium, approximately50% is bound to serum proteins or complexed with anions and 50% is in the ionized form. Totalserum calcium is dependent on serum protein concentrations. Total serum calcium changes byapproximately 0.8 mg/dl for every 1.09 g/dl change in serum albumin. Calcium crosses the placentaand is distributed into milk.
Calcium is eliminated primarily in the feces, contributed by both unabsorbed calcium and calciumexcreted into the bile and pancreatic juice. Only small amounts of the drug are excreted in the urine, as most of the cation filtered by the glomeruli is reabsorbed by the tubules and ascending loop of
Henle. Vitamin D, parathormone, and thiazide diuretics decrease the amount of calcium excreted bythe kidneys. Loop diuretics (e.g., furosemide), calcitonin, and somatotropin increase calcium renalexcretion.

Contraindications, Precautions, Reproductive Safety

Calcium is contraindicated in patientswith ventricular fibrillation or with hypercalcemia. Parenteral calcium should not be administered topatients with above normal serum calcium levels. Calcium should be used very cautiously inpatients receiving digitalis glycosides, or with cardiac or renal disease. Calcium chloride, because itcan be acidifying, should be used with caution in patients with respiratory failure, respiratoryacidosis, or renal disease.
Although parenteral calcium products have not been proven to be safe to use during pregnancy, they are often used before, during, and after parturition in cows, ewes, bitches, and queens to treatparturient paresis secondary to hypocalcemia.

Adverse Effects, Warnings

Hypercalcemia can be associated with calcium therapy, particularlyin patients with cardiac or renal disease; animals should be adequately monitored. Other effects thatmay be seen include GI irritation and/or constipation after oral administration, mild to severe tissuereactions after IM or SQ administration of calcium salts and venous irritation after IVadministration. Calcium chloride may be more irritating than other parenteral salts and is morelikely to cause hypotension. Too rapid intravenous injection of calcium can cause hypotension, cardiac arrhythmias and cardiac arrest.
Should calcium salts be infused perivascularly, first stop the infusion. Ttreatment may then include: infiltrate the affected area with normal saline, corticosteroids administered locally, apply heatand elevate the area, and infiltrate affected area with 1% procaine and hyaluronidase.
Overdosage, Acute Toxicity - Unless other drugs are given concurrently that enhance the absorption of calcium, oral overdoses of calcium containing products are unlikely to cause hypercalcemia. Hypercalcemia can occur with parenteral therapy or oral therapy in combination withvitamin D or increased parathormone levels. Hypercalcemia should be treated by withholdingcalcium therapy and other calcium elevating drugs (e.g., vitamin D analogs). Mild hypercalcemiasgenerally will resolve without further intervention when renal function is adequate.
More serious hypercalcemias (>12 mg/dl) should generally be treated by hydrating with IVnormal saline and administering a loop diuretic (e.g., furosemide) to increase both sodium andcalcium excretion. Potassium and magnesium must be monitored and replaced as necessary. ECGshould also be monitored during treatment. Corticosteroids, and in humans, calcitonin andhemodialysis have also been employed in treating hypercalcemia.

Drug Interactions

Patients on digitalis therapy are more apt to develop arrhythmias if receiving IV calcium¯use with caution. Calcium may antagonize the effects of verapamil (and othercalcium-channel blocking agents).
Thiazide diuretics used in conjunction with large doses of calcium may cause hypercalcemia.
Oral magnesium products with oral calcium may lead to increased serum magnesium and/orcalcium, particularly in patients with renal failure. Parenteral calcium can neutralize the effects ofhypermagnesemia or magnesium toxicity secondary to parenteral magnesium sulfate.
Parenteral calcium may reverse the effects of nondepolarizing neuromuscular blocking agents(e.g., metubine, gallamine, pancuronium, atracurium, & vecuronium). Calcium has been reported toprolong or enhance the effects of tubocurarine.
Oral calcium can reduce the amount of phenytoin or tetracyclines absorbed from the GI tract.
Patients receiving both parenteral calcium and potassium supplementation may have an increasedchance of developing cardiac arrhythmias¯use cautiously.
Excessive intake of vitamin A may stimulate calcium loss from bone and cause hypercalcemia.
Concurrent use of large doses of vitamin D or its analogs may cause enhanced calcium absorption and induce hypercalcemia.
Drug/Laboratory Interactions - Parenteral calcium may cause false-negative results for serumand urinary magnesium when using the Titan yellow method of determination.
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