Note: One gram of calcium citrate is equal to 211 mg of elemental calcium.
Calcium supplementation (OTC labeling): Oral: 200 mg to 1 g/day (as elemental calcium) as a single dose or in divided doses.
Note: The recommended daily intake of elemental calcium (from dietary sources and supplemental sources if needed) for optimal bone health is 1.2 g/day (postmenopausal women) or 1 to 1.2 g/day in other adults. It is preferred to obtain these daily amounts primarily through dietary sources. There is no evidence that intakes higher than these improve bone strength (AACE [Camacho 2020]; ES [Watts 2012]; IOM 2011; NOF [Cosman 2014]).
Hypocalcemia, chronic (off-label use):
Note: Use of IV calcium may be required in patients who become unable to take or absorb oral calcium. Vitamin D replacement may also be required depending on the cause of hypocalcemia (eg, hypoparathyroidism, vitamin D deficiency) . Correct concurrent hypomagnesemia if present (ES [Bilezikian 2016]; Fong 2012). These recommendations do not apply to patients with chronic kidney disease; refer to specific dosing recommendations in this population (eg, for hyperphosphatemia).
Oral: Initial: 1 to 2 g/day of elemental calcium administered in 2 to 3 divided doses; adjust dose as needed to control symptoms and maintain albumin-corrected calcium levels in the low-normal range (ES [Bilezikian 2016]; Goltzman 2022a).
Hypoparathyroidism, acute postsurgical, mild (off-label use):
Note: For use in patients with mild symptoms (eg, oral paresthesias) and/or an albumin-corrected serum calcium level below normal but ≥7.5 mg/dL (≥1.87 mmol/L); use of IV calcium is required in patients with more severe symptoms of hypocalcemia, patients unable to take or absorb oral calcium, or patients whose symptoms do not improve with oral therapy. Correct concurrent hypomagnesemia if present and initiate vitamin D replacement as soon as feasible (ES [Bilezikian 2016]; Fong 2012; Goltzman 2022b).
Oral: Initial: 1 to 4 g/day of elemental calcium administered in 2 to 3 divided doses; adjust dose as needed to control symptoms and maintain albumin-corrected calcium levels in the low-normal range (ES [Bilezikian 2016]; Goltzman 2022b). Note: Postsurgical hypoparathyroidism may be transient; attempt a slow taper of calcium and vitamin D supplements starting 3 to 6 weeks after surgery (Goltzman 2022b).
Dosage adjustment for concomitant therapy: Significant drug interactions exist, requiring dose/frequency adjustment or avoidance. Consult drug interactions database for more information.
(For additional information see "Calcium citrate: Pediatric drug information")
Note: Calcium citrate 1,000 mg = 211 mg elemental calcium = 10.5 mEq calcium
Hypocalcemia, asymptomatic: Limited data available: Infants, Children, and Adolescents: Dose expressed as elemental calcium: Oral: 30 to 75 mg/kg/day in 4 to 5 divided doses (Lynch 2017; Root 2020).
Dosage adjustment for concomitant therapy: Significant drug interactions exist, requiring dose/frequency adjustment or avoidance. Consult drug interactions database for more information.
Initiate at the lowest dose of the recommended dosage range; monitor serum calcium concentrations closely. Accumulation may occur with renal impairment and subsequent doses may require adjustment based on serum calcium concentrations.
There are no dosage adjustments provided in the manufacturer's labeling. No initial dosage adjustment necessary; subsequent doses should be guided by serum calcium concentrations.
The following adverse drug reactions and incidences are derived from product labeling unless otherwise specified. Frequency not defined. Mild hypercalcemia (calcium: >10.5 mg/dL) may be asymptomatic or manifest as anorexia, constipation, nausea, and vomiting. More severe hypercalcemia (calcium: >12 mg/dL) is associated with coma, confusion, delirium, and stupor.
Central nervous system: Headache
Endocrine & metabolic: Hypercalcemia, hypophosphatemia, increased thirst
Gastrointestinal: Abdominal pain, anorexia, constipation, nausea, vomiting
Concerns related to adverse effects:
• GI effects: Constipation, bloating, and gas are common with calcium supplements (especially carbonate salt).
• Hypercalcemia: Chronic hypercalcemia may result in generalized vascular and soft tissue calcification, exacerbate nephrolithiasis, and has been associated with increased mortality in adults with chronic kidney disease (CKD) (KDIGO 2017).
Disease-related concerns:
• Achlorhydria: Calcium absorption is impaired in achlorhydria; common in elderly. Citrate may be preferred because better absorbed.
• Hypoparathyroid disease: Hypercalcemia and hypercalciuria are most likely to occur in hypoparathyroid patients receiving high doses of vitamin D.
• Kidney stones (calcium-containing): Use caution when administering calcium supplements to patients with a history of kidney stones.
• Renal impairment: Use with caution in patients with renal failure to avoid hypercalcemia; frequent monitoring of serum calcium and phosphorus is necessary.
Other warnings/precautions:
• Appropriate product selection: Multiple salt forms of calcium exist; close attention must be paid to the salt form when ordering and administering calcium; incorrect selection or substitution of one salt for another without proper dosage adjustment may result in serious over or under dosing.
1 g calcium citrate = elemental calcium 211 mg = calcium 10.5 mEq = calcium 5.25 mmol
Excipient information presented when available (limited, particularly for generics); consult specific product labeling. [DSC] = Discontinued product
Capsule, Oral, as citrate [preservative free]:
Cal-Citrate: 150 mg [dye free]
Granules, Oral:
Generic: 760 mg/3.5 g (480 g)
Tablet, Oral:
Generic: 1040 mg [DSC], 250 mg (elemental calcium)
Tablet, Oral [preservative free]:
Calcitrate: 200 mg (elemental calcium) [DSC] [lactose free, milk derivatives/products, no artificial color(s), no artificial flavor(s), sodium free, soy free, sugar free, wheat free, yeast free]
Generic: 200 mg (elemental calcium)
Yes
Tablets (Calcium Citrate Oral)
950 (200 Ca) mg (per each): $0.04
Disclaimer: A representative AWP (Average Wholesale Price) price or price range is provided as reference price only. A range is provided when more than one manufacturer's AWP price is available and uses the low and high price reported by the manufacturers to determine the range. The pricing data should be used for benchmarking purposes only, and as such should not be used alone to set or adjudicate any prices for reimbursement or purchasing functions or considered to be an exact price for a single product and/or manufacturer. Medi-Span expressly disclaims all warranties of any kind or nature, whether express or implied, and assumes no liability with respect to accuracy of price or price range data published in its solutions. In no event shall Medi-Span be liable for special, indirect, incidental, or consequential damages arising from use of price or price range data. Pricing data is updated monthly.
May administer with or without food; administration with food may increase absorption. Doses >600 mg (elemental calcium) per day should be divided for optimal absorption (AACE [Camacho 2020]).
Oral: May administer with or without food (AAP [Golden 2014]; Straub 2007). Administration with food may increase absorption (Straub 2007).
Calcium supplementation: Use as a dietary supplement when calcium intake may be inadequate (eg, osteoporosis, osteomalacia, hypocalcemic rickets) (IOM 2011)
Hypocalcemia, chronic; Hypoparathyroidism, acute postsurgical, mild
Citracal may be confused with Citrucel
None known.
Note: Interacting drugs may not be individually listed below if they are part of a group interaction (eg, individual drugs within “CYP3A4 Inducers [Strong]” are NOT listed). For a complete list of drug interactions by individual drug name and detailed management recommendations, use the Lexicomp drug interactions program by clicking on the “Launch drug interactions program” link above.
Alpha-Lipoic Acid: Calcium Salts may decrease the absorption of Alpha-Lipoic Acid. Alpha-Lipoic Acid may decrease the absorption of Calcium Salts. Management: Separate administration of alpha-lipoic acid from that of any calcium-containing compounds by several hours. If alpha-lipoic acid is given 30 minutes before breakfast, then administer oral calcium-containing products at lunch or dinner. Risk D: Consider therapy modification
Aluminum Hydroxide: Citric Acid Derivatives may increase the absorption of Aluminum Hydroxide. Risk C: Monitor therapy
Baloxavir Marboxil: Polyvalent Cation Containing Products may decrease the serum concentration of Baloxavir Marboxil. Risk X: Avoid combination
Bictegravir: Calcium Salts may decrease the serum concentration of Bictegravir. Management: Bictegravir, emtricitabine, and tenofovir alafenamide can be administered with calcium salts under fed conditions, but coadministration with or 2 hours after a calcium salt is not recommended under fasting conditions. Risk D: Consider therapy modification
Bisphosphonate Derivatives: Polyvalent Cation Containing Products may decrease the serum concentration of Bisphosphonate Derivatives. Management: Avoid administration of oral medications containing polyvalent cations within: 2 hours before or after tiludronate/clodronate/etidronate; 60 minutes after oral ibandronate; or 30 minutes after alendronate/risedronate. Risk D: Consider therapy modification
Cabotegravir: Polyvalent Cation Containing Products may decrease the serum concentration of Cabotegravir. Management: Administer polyvalent cation containing products at least 2 hours before or 4 hours after oral cabotegravir. Risk D: Consider therapy modification
Calcium Acetate: Calcium Salts may enhance the adverse/toxic effect of Calcium Acetate. Risk X: Avoid combination
Calcium Channel Blockers: Calcium Salts may diminish the therapeutic effect of Calcium Channel Blockers. Risk C: Monitor therapy
Cardiac Glycosides: Calcium Salts may enhance the arrhythmogenic effect of Cardiac Glycosides. Risk C: Monitor therapy
Deferiprone: Polyvalent Cation Containing Products may decrease the serum concentration of Deferiprone. Management: Separate administration of deferiprone and oral medications or supplements that contain polyvalent cations by at least 4 hours. Risk D: Consider therapy modification
DOBUTamine: Calcium Salts may diminish the therapeutic effect of DOBUTamine. Risk C: Monitor therapy
Dolutegravir: Calcium Salts may decrease the serum concentration of Dolutegravir. Management: Administer dolutegravir at least 2 hours before or 6 hours after oral calcium. Administer dolutegravir/rilpivirine at least 4 hours before or 6 hours after oral calcium salts. Alternatively, dolutegravir and oral calcium can be taken together with food. Risk D: Consider therapy modification
Eltrombopag: Polyvalent Cation Containing Products may decrease the serum concentration of Eltrombopag. Management: Administer eltrombopag at least 2 hours before or 4 hours after oral administration of any polyvalent cation containing product. Risk D: Consider therapy modification
Elvitegravir: Polyvalent Cation Containing Products may decrease the serum concentration of Elvitegravir. Management: Administer elvitegravir 2 hours before or 6 hours after the administration of polyvalent cation containing products. Risk D: Consider therapy modification
Estramustine: Calcium Salts may decrease the absorption of Estramustine. Management: Administer estramustine on an empty stomach, at least 1 hour before or 2 hours after the dose of an oral calcium supplement. If coadministered with calcium salts, monitor for decreased estramustine therapeutic effects. Risk D: Consider therapy modification
Levonadifloxacin: Calcium Salts may decrease the serum concentration of Levonadifloxacin. Risk X: Avoid combination
Multivitamins/Fluoride (with ADE): May increase the serum concentration of Calcium Salts. Calcium Salts may decrease the serum concentration of Multivitamins/Fluoride (with ADE). More specifically, calcium salts may impair the absorption of fluoride. Management: Avoid eating or drinking dairy products or consuming vitamins or supplements with calcium salts one hour before or after of the administration of fluoride. Risk D: Consider therapy modification
Multivitamins/Minerals (with ADEK, Folate, Iron): May increase the serum concentration of Calcium Salts. Risk C: Monitor therapy
PenicillAMINE: Polyvalent Cation Containing Products may decrease the serum concentration of PenicillAMINE. Management: Separate the administration of penicillamine and oral polyvalent cation containing products by at least 1 hour. Risk D: Consider therapy modification
Phosphate Supplements: Calcium Salts may decrease the absorption of Phosphate Supplements. Management: This applies only to oral phosphate and calcium administration. Administering oral phosphate supplements as far apart from the administration of an oral calcium salt as possible may be able to minimize the significance of the interaction. Risk D: Consider therapy modification
Quinolones: Calcium Salts may decrease the absorption of Quinolones. Of concern only with oral administration of both agents. Management: Consider administering an oral quinolone at least 2 hours before or 6 hours after the dose of oral calcium to minimize this interaction. Monitor for decreased therapeutic effects of quinolones during coadministration. Risk D: Consider therapy modification
Raltegravir: Polyvalent Cation Containing Products may decrease the serum concentration of Raltegravir. Management: Administer raltegravir 2 hours before or 6 hours after administration of the polyvalent cations. Dose separation may not adequately minimize the significance of this interaction. Risk D: Consider therapy modification
Roxadustat: Polyvalent Cation Containing Products may decrease the serum concentration of Roxadustat. Management: Administer roxadustat at least 1 hour after the administration of oral polyvalent cation containing products. Risk D: Consider therapy modification
Strontium Ranelate: Calcium Salts may decrease the serum concentration of Strontium Ranelate. Management: Separate administration of strontium ranelate and oral calcium salts by at least 2 hours in order to minimize this interaction. Risk D: Consider therapy modification
Tetracyclines: Calcium Salts may decrease the serum concentration of Tetracyclines. Management: If coadministration of oral calcium with oral tetracyclines cannot be avoided, consider separating administration of each agent by several hours. Risk D: Consider therapy modification
Thiazide and Thiazide-Like Diuretics: May increase the serum concentration of Calcium Salts. Risk C: Monitor therapy
Thyroid Products: Calcium Salts may diminish the therapeutic effect of Thyroid Products. Management: Separate the doses of the thyroid product and the oral calcium supplement by at least 4 hours. Monitor for decreased therapeutic effects of thyroid products if an oral calcium supplement is initiated/dose increased. Risk D: Consider therapy modification
Trientine: Polyvalent Cation Containing Products may decrease the serum concentration of Trientine. Management: Avoid concomitant use of trientine and polyvalent cations. If oral iron supplements are required, separate the administration by 2 hours. For other oral polyvalent cations, give trientine 1 hour before, or 1 to 2 hours after the polyvalent cation. Risk D: Consider therapy modification
Unithiol: May diminish the therapeutic effect of Polyvalent Cation Containing Products. Risk X: Avoid combination
Vitamin D Analogs: Calcium Salts may enhance the adverse/toxic effect of Vitamin D Analogs. Risk C: Monitor therapy
Calcium crosses the placenta. Intestinal absorption of calcium increases during pregnancy. The amount of calcium reaching the fetus is determined by maternal physiological changes. Calcium requirements are the same in pregnant and nonpregnant females (IOM 2011).
Calcium is present in breast milk. The amount of calcium in breast milk is homeostatically regulated and not altered by maternal calcium intake. Calcium requirements are the same in lactating and nonlactating females (IOM 2011).
Dietary reference intake for calcium (IOM 2011):
0 to <6 months: Adequate intake: 200 mg elemental calcium/day.
6 to 12 months: Adequate intake: 260 mg elemental calcium/day.
1 to 3 years: Recommended dietary allowance (RDA): 700 mg elemental calcium/day.
4 to 8 years: RDA: 1,000 mg elemental calcium/day.
9 to 18 years: RDA: 1,300 mg elemental calcium/day.
19 to 50 years: RDA: 1,000 mg elemental calcium/day.
51 to 70 years: RDA:
Females: 1,200 mg elemental calcium/day.
Males: 1,000 mg elemental calcium/day.
>70 years: RDA: 1,200 mg elemental calcium/day.
Pregnancy/Lactating: RDA: Requirements are the same as in nonpregnant or nonlactating females.
Monitor plasma calcium levels if using calcium salts as electrolyte supplements for deficiency.
Calcium supplementation in hypoparathyroidism (ES [Brandi 2016]): Note: Frequency of measurement is dependent upon on how stable a patient is to a given dosage regimen with more frequent measurements (eg, weekly) required initially during dosage titration. Once patient is well controlled, monitoring may be required on a yearly or twice-yearly basis.
Serum calcium, phosphate, and magnesium; renal function (ie, 24-hour urinary calcium and creatinine, BUN), measured CrCl or eGFR; renal imaging (every 5 years in asymptomatic patients with a history of renal lithiasis or calcinosis or more frequently as indicated); CNS imaging (basal ganglia and other sites of calcification), ophthalmologic exam, and/or BMD as clinically indicated.
Serum calcium: 8.6 to 10.2 mg/dL (SI: 2.2 to 2.6 mmol/L).
Due to a poor correlation between the serum ionized calcium (free) and total serum calcium, particularly in states of low albumin or acid/base imbalances, direct measurement of ionized calcium is recommended
In low albumin states, the corrected total serum calcium may be estimated by:
Corrected total calcium (mg/dL) = measured serum calcium (mg/mL) + 0.8 (4 - measured serum albumin [g/dL])
or
Corrected total calcium (mmol/L) = measured serum calcium (mmol/L) + 0.02 (40 - measured serum albumin [g/L])
Calcium supplementation in hypoparathyroidism (ES [Brandi 2016]):
Correct serum calcium to low-normal range or no more than 0.5 mg/dL below normal; calcium-phosphate product <55 mg2/dL2
Moderates nerve and muscle performance via action potential excitation threshold regulation
Absorption: 25% to 35%, requires vitamin D; varies with age (infants 60%, prepubertal children 28%, pubertal children 34%, young adults 25%); decreased absorption occurs in patients with achlorhydria, renal osteodystrophy, steatorrhea, or uremia
Protein binding: 45%
Excretion: Primarily in the feces as unabsorbed calcium
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