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Calcium chloride: Drug information

Calcium chloride: Drug information
(For additional information see "Calcium chloride: Patient drug information" and see "Calcium chloride: Pediatric drug information")

For abbreviations, symbols, and age group definitions used in Lexicomp (show table)
Brand Names: Canada
  • Calciject
Pharmacologic Category
  • Calcium Salt;
  • Electrolyte Supplement, Parenteral
Dosing: Adult

Note: One gram of calcium chloride salt is equal to 270 mg of elemental calcium.

Dosages are expressed in terms of the calcium chloride salt (unless otherwise specified as elemental calcium). Dosages expressed in terms of the calcium chloride salt are based on a solution concentration of 100 mg/mL (10%) containing 1.4 mEq (27 mg) elemental calcium per mL.

Beta-blocker overdose

Beta-blocker overdose (off-label use): Based on limited data: IV: Initial: Using a 10% solution: 20 mg/kg over 5 to 10 minutes (maximum: 1 to 2 g/dose); may repeat every 10 to 20 minutes for 3 to 4 additional doses or initiate a continuous infusion of 20 to 40 mg/kg/hour titrated to improve hemodynamic response (Ref).

Calcium channel blocker overdose

Calcium channel blocker overdose (off-label use): Based on limited data: IV: Initial: Using a 10% solution: 20 mg/kg over 5 to 10 minutes (maximum: 1 to 2 g/dose); may repeat every 10 to 20 minutes for 3 to 4 additional doses or initiate a continuous infusion of 20 to 40 mg/kg/hour titrated to improve hemodynamic response (Ref). Note: Some recommend maintaining serum ionized calcium at a goal of twice normal (Ref).

Calcium replacement, during CRRT with citrate-based regional anticoagulation

Calcium replacement, during CRRT with citrate-based regional anticoagulation (off-label dose):

Intracircuit, posthemodialysis filter (returning to the patient) or IV through a separate central line: Prior to the initiation of CRRT, ensure adequate systemic ionized calcium concentrations (drawn directly from the patient). During CRRT, use a calcium chloride continuous infusion sliding scale to maintain systemic ionized calcium between ~3.6 to 5.2 mg/dL (~0.9 to 1.3 mmol/L); monitor systemic ionized calcium every 6 hours (or more frequently when indicated) (Ref). Refer to institutional protocols.

Cardiac arrest or cardiotoxicity in the presence of hypocalcemia or hypermagnesemia

Cardiac arrest or cardiotoxicity in the presence of hypocalcemia or hypermagnesemia (off-label use): Note: Routine use in cardiac arrest is not recommended due to the lack of improved survival (Ref).

IV, Intraosseous: 500 to 1,000 mg as a rapid bolus; may repeat as necessary (Ref).

Hydrofluoric acid exposure

Hydrofluoric acid exposure (off-label use): Note: Consultation with a clinical toxicology or poison control center is recommended prior to the use of calcium chloride for hydrofluoric acid exposure.

Systemic toxicity: Note: Calcium chloride has been used in the treatment of systemic toxicity secondary to hydrofluoric acid exposure (Ref); however, calcium gluconate may be preferred due to the potential for more severe extravasation with calcium chloride.

IV: Exact dose has not been established; clinicians should tailor dose based on patient-specific needs (Ref). Bolus doses of up to 4 g have been required (Ref); repeat as needed based on symptoms of toxicity (eg, cardiac arrhythmias) and serum calcium concentration.

Hydrofluoric acid burns (severe): Intra-arterial: 10% solution: Add 10 mL of a 10% solution in 40 to 50 mL of D5W; infuse over 4 hours into the artery that provides the vascular supply to the affected area. Pain usually resolves by the end of the infusion; repeat if pain recurs (Ref); calcium gluconate may be preferred due to the potential for vessel injury and extravasation (Ref). This intervention should be used only by those accustomed to this technique. Care should be taken to avoid the extravasation. A poison information center or clinical toxicologist should be consulted prior to implementation.

Hyperkalemia, severe/emergent

Hyperkalemia , severe/emergent (off-label use): Note: Use in patients with hyperkalemia-associated ECG changes or serum potassium >6.5 mEq/L (Ref). Stabilizes myocardial cell membrane without impacting plasma potassium concentrations; must combine with insulin/dextrose to decrease plasma potassium levels and other therapies to eliminate potassium from body (Ref). Perform continuous cardiac monitoring and obtain serial ECGs (Ref).

IV, Intraosseous: Initial: 0.5 to 1 g over 2 to 5 minutes; may repeat after 5 minutes if ECG changes persist or recur, then every 30 to 60 minutes as needed (Ref).

Hypocalcemia, acute

Hypocalcemia, acute (alternative agent):

Note: For use in patients with severe symptoms of hypocalcemia (eg, tetany, seizures, carpopedal spasm), ECG abnormalities (eg, QTc prolongation, arrhythmia), or an acute decrease in albumin-corrected serum calcium levels to <7 to 7.5 mg/dL (<1.75 to 1.87 mmol/L) when serious complications may occur if untreated (eg, following neck surgery). In patients without a central line, calcium gluconate is preferred over calcium chloride due to the potential for more severe extravasation with calcium chloride. Correct concurrent hypomagnesemia if present (Ref). Do not use IV calcium as initial therapy in patients with chronic kidney disease who are asymptomatic or who have stable hypocalcemia with only mild symptoms (eg, paresthesias) (Ref).

Initial bolus dose(s): IV: Add 1 g (10 mL of a 10% solution) to 100 mL of D5W or NS (equivalent to 270 mg elemental calcium). Infuse via a central or large vein over 10 to 20 minutes; may repeat bolus dose after 10 to 60 minutes if symptoms persist (Ref). If hypocalcemia is expected to persist (eg, hypoparathyroidism, pancreatitis), follow bolus dose(s) with a continuous IV calcium infusion (Ref).

Continuous infusion: IV: Add 4 g (40 mL of a 10% solution) to 960 mL of D5W or NS (equivalent to ~1 g elemental calcium in a final total volume of 1,000 mL). Initiate infusion at 50 to 100 mL/hour (equivalent to ~50 to 100 mg/hour of elemental calcium) via a central or large vein; adjust dose to maintain albumin-corrected serum calcium levels at the low end of normal (Ref). Initiate oral calcium and vitamin D supplements as soon as possible; once an effective regimen is achieved, taper IV calcium infusion slowly (eg, over 24 to 48 hours) (Ref). Note: Instructions for preparing calcium chloride infusion are adapted from recommendations for calcium gluconate (Ref).

Dosing: Kidney Impairment: Adult

Note: Do not use IV calcium as initial therapy in patients with chronic kidney disease who are asymptomatic or who have stable hypocalcemia with only mild symptoms (eg, paresthesias) (Ref).

Initiate with lowest dose of the recommended dosage range.

Dosing: Hepatic Impairment: Adult

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.

Dosing: Older Adult

Refer to adult dosing.

Dosing: Pediatric

(For additional information see "Calcium chloride: Pediatric drug information")

Note: 1 g of calcium chloride salt is equal to 273 mg of elemental calcium.

Daily maintenance calcium

Daily maintenance calcium: Dosage expressed in terms of elemental calcium.

Infants and Children <25 kg: IV: 1 to 2 mEq/kg/day.

Children 25 to 45 kg: IV: 0.5 to 1.5 mEq/kg/day.

Children >45 kg and Adolescents: IV: 0.2 to 0.3 mEq/kg/day or 10 to 20 mEq/day.

Parenteral nutrition, maintenance calcium requirement

Parenteral nutrition, maintenance calcium requirement (Ref): Note: Dosage expressed in terms of elemental calcium.

Infants and Children ≤50 kg: IV: 0.5 to 4 mEq/kg/day as an additive to parenteral nutrition solution.

Children >50 kg and Adolescents: IV: 10 to 20 mEq/day as an additive to parenteral nutrition solution.

Hypocalcemia

Hypocalcemia: Note: In general, IV calcium gluconate is preferred over IV calcium chloride in nonemergency settings due to the potential for extravasation with calcium chloride. Dosage expressed in mg of calcium chloride.

Infants, Children, and Adolescents:

Manufacturer's recommendations: IV: 2.7 to 5 mg/kg/dose every 4 to 6 hours; maximum dose: 1,000 mg.

Alternative dosing: IV: 10 to 20 mg/kg/dose; maximum dose: 1,000 mg; repeat every 4 to 6 hours if needed.

Cardiac arrest in the presence of hyperkalemia or hypocalcemia, hypermagnesemia, or calcium channel antagonist toxicity

Cardiac arrest in the presence of hyperkalemia or hypocalcemia, hypermagnesemia, or calcium channel antagonist toxicity (PALS recommendations): Infants, Children, and Adolescents: Dosage expressed in mg of calcium chloride: IV, Intraosseous: 20 mg/kg/dose (maximum dose: 2,000 mg); may repeat in 10 minutes if necessary; if effective, consider IV infusion of 20 to 50 mg/kg/hour; Note: Routine use in cardiac arrest is not recommended due to the lack of improved survival (Ref).

Calcium channel blocker toxicity

Calcium channel blocker toxicity: Infants, Children, and Adolescents: Dosage expressed in mg of calcium chloride: IV: 20 mg/kg/dose infused over 5 to 10 minutes; if effective, consider IV infusion of 20 to 50 mg/kg/hour (Ref).

Hypocalcemia secondary to citrated blood infusion

Hypocalcemia secondary to citrated blood infusion: Infants, Children, and Adolescents: IV: 0.45 mEq elemental calcium for each 100 mL citrated blood infused.

Tetany

Tetany: Infants, Children, and Adolescents: Dosage expressed in mg of calcium chloride: IV: 10 mg/kg over 5 to 10 minutes; may repeat after 6 hours or follow with an infusion with a maximum dose of 200 mg/kg/day.

Dosing: Kidney Impairment: Pediatric

No initial dosage adjustment necessary; however, accumulation may occur with renal impairment and subsequent doses may require adjustment based on serum calcium concentrations.

Dosing: Hepatic Impairment: Pediatric

No initial dosage adjustment necessary; subsequent doses should be guided by serum calcium concentrations.

Adverse Reactions

The following adverse drug reactions are derived from product labeling unless otherwise specified.

Postmarketing:

Cardiovascular: Cardiac arrhythmia (Carlon 1978), hypotension (Carlon 1978), peripheral vasodilation

Dermatologic: Cutaneous calcification (Ehsani 2006)

Gastrointestinal: Medicine-like taste (calcium taste)

Local: Injection-site reaction, localized burning

Contraindications

Patients with ventricular fibrillation; patients with asystole and electromechanical dissociation; concomitant use of IV calcium chloride with ceftriaxone in neonates (≤28 days of age).

Significant drug interactions exist, requiring dose/frequency adjustment or avoidance. Consult drug interactions database for more information.

Warnings/Precautions

Concerns related to adverse effects:

• Extravasation: Vesicant; ensure proper catheter or needle position prior to and during infusion. Avoid extravasation. Extravasation may result in severe necrosis and sloughing. Monitor the IV site closely.

Disease-related concerns:

• Acidosis: Use with caution in patients with respiratory acidosis, renal impairment, or respiratory failure; acidifying effect of calcium chloride may potentiate acidosis.

• Hydrofluoric acid burns: Calcium chloride can be administered intra-arterially for severe hydrofluoric acid exposures. However, the chloride salt should never be injected into tissues (do not inject SUBQ or IM) due to the risk of tissue necrosis (Smith 2019). Consultation with a clinical toxicologist or a poison information center before using calcium chloride to treat hydrofluoric acid toxicity is recommended.

• Hyperphosphatemia: Use with caution in patients with severe hyperphosphatemia as elevated levels of phosphorus and calcium may result in soft tissue and pulmonary arterial calcium-phosphate precipitation.

• Hypokalemia: Use with caution in patients with severe hypokalemia as acute rises in serum calcium levels may result in life-threatening cardiac arrhythmias.

• Hypomagnesemia: Hypomagnesemia is a common cause of hypocalcemia; therefore, correction of hypocalcemia may be difficult in patients with concomitant hypomagnesemia. Evaluate serum magnesium and correct hypomagnesemia (if necessary), particularly if initial treatment of hypocalcemia is refractory.

• Renal impairment: Use with caution in patients with chronic renal failure to avoid hypercalcemia; frequent monitoring of serum calcium and phosphorus is necessary.

Concurrent drug therapy issues:

• Ceftriaxone: Ceftriaxone may complex with calcium causing precipitation. Fatal lung and kidney damage associated with calcium-ceftriaxone precipitates has been observed in premature and term neonates. Due to reports of precipitation reaction in neonates, do not coadminister ceftriaxone with calcium-containing solutions, even via separate infusion lines/sites or at different times in any neonate. Ceftriaxone should not be administered simultaneously with any calcium-containing solution via a Y-site in any patient. However, ceftriaxone and calcium-containing solutions may be administered sequentially of one another for use in patients other than neonates if infusion lines are thoroughly flushed (with a compatible fluid) between infusions.

• Digoxin: Use with caution in digitalized patients; hypercalcemia may precipitate cardiac arrhythmias.

Dosage form specific issues:

• Aluminum: The parenteral product may contain aluminum; toxic aluminum concentrations may be seen with high doses, prolonged use, or renal dysfunction. Premature neonates are at higher risk due to immature renal function and aluminum intake from other parenteral sources. Parenteral aluminum exposure of >4 to 5 mcg/kg/day is associated with CNS and bone toxicity; tissue loading may occur at lower doses (Federal Register, 2002). See manufacturer’s labeling.

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.

• Duration of use: Avoid metabolic acidosis (ie, administer only up to 2 to 3 days then change to another calcium salt).

• IV administration: For IV use only; do not inject SUBQ or IM. Avoid too rapid IV administration (do not exceed 100 mg/minute except in emergency situations); arrythmia, bradycardia, cardiac arrest, hypotension, syncope, and vasodilation may occur.

Dosage Forms Considerations

1 g calcium chloride = elemental calcium 273 mg = calcium 13.6 mEq = calcium 6.8 mmol

Dosage Forms: US

Excipient information presented when available (limited, particularly for generics); consult specific product labeling.

Solution, Intravenous:

Generic: 10% (10 mL)

Solution, Intravenous [preservative free]:

Generic: 10% (10 mL)

Generic Equivalent Available: US

Yes

Pricing: US

Solution (Calcium Chloride Intravenous)

10% (per mL): $0.89 - $2.43

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.

Dosage Forms: Canada

Excipient information presented when available (limited, particularly for generics); consult specific product labeling.

Solution, Intravenous:

Calciject: 10% (10 mL, 50 mL)

Generic: 10% (10 mL)

Administration: Adult

IV: For IV administration only. Not for IM or SUBQ administration (severe necrosis and sloughing may occur). Avoid rapid administration (do not exceed 100 mg/minute except in emergency situations). For patients in cardiac arrest, administer as a rapid bolus via a central line or intraosseous route (Ref). For intermittent IV infusion, infuse diluted solution over 1 hour or no greater than 45 to 90 mg/kg/hour (0.6 to 1.2 mEq/kg/hour); administration via a central or deep vein is preferred; do not use small hand or foot veins for IV administration (severe necrosis and sloughing may occur). Typical rates of administration may vary with indication; refer to institutional protocol. Monitor ECG if calcium is infused faster than 2.5 mEq/minute; stop the infusion if the patient complains of pain or discomfort. Warm solution to body temperature prior to administration. Do not infuse calcium chloride in the same IV line as phosphate-containing solutions.

Hydrofluoric acid burns (severe) (off-label use/route): Intra-arterial: Requires radiology to place an arterial catheter in an artery supplying blood to the area of exposure; infuse over 4 hours (Ref). This intervention should be used only by those trained in this technique. Care should be taken to avoid the extravasation. A poison information center or clinical toxicologist should be consulted prior to implementation.

Vesicant; ensure proper needle or catheter placement prior to and during IV infusion. Avoid extravasation.

Extravasation management:

Early/acute calcium extravasation: If extravasation occurs, stop infusion immediately; leave needle/cannula in place temporarily but do NOT flush the line; gently aspirate extravasated solution, then remove needle/cannula; elevate extremity; apply dry warm compresses; initiate hyaluronidase antidote (Ref).

Hyaluronidase: Intradermal or SUBQ: Inject a total of 1 to 1.7 mL (15 units/mL) as 5 separate 0.2 to 0.3 mL injections (using a tuberculin syringe) around the site of extravasation; if IV catheter remains in place, administer intravenously through the infiltrated catheter; may repeat in 30 to 60 minutes if no resolution (Ref).

Delayed calcium extravasation: Closely monitor site; most calcifications spontaneously resolve. However, if a severe manifestation of calcinosis cutis occurs, may initiate sodium thiosulfate antidote.

Sodium thiosulfate: IV: 12.5 g over 30 minutes, administered 3 times per week; may increase gradually to 25 g 3 times per week; monitor for non-anion gap acidosis, hypocalcemia, severe nausea (Ref).

Administration: Pediatric

Parenteral: Do not use scalp vein or small hand or foot veins for IV administration; central-line administration is the preferred route. Not for endotracheal administration. Do not inject calcium salts IM or administer SubQ since severe necrosis and sloughing may occur; extravasation of calcium can result in severe necrosis and tissue sloughing. Stop the infusion if the patient complains of pain or discomfort. Warm solution to body temperature prior to administration. Do not infuse calcium chloride in the same IV line as phosphate-containing solutions.

IV: For direct IV injection infuse slow IVP over 3 to 5 minutes or at a maximum rate of 50 to 100 mg calcium chloride/minute; in situations of cardiac arrest, calcium chloride may be administered over 10 to 20 seconds.

IV infusion: Further dilute and administer 45 to 90 mg calcium chloride/kg over 1 hour; 0.6 to 1.2 mEq calcium/kg over 1 hour

Parenteral nutrition solution: Although calcium chloride is not routinely used in the preparation of parenteral nutrition, it is important to note that calcium-phosphate stability in parenteral nutrition solutions is dependent upon the pH of the solution, temperature, and relative concentration of each ion. The pH of the solution is primarily dependent upon the amino acid concentration. The higher the percentage amino acids, the lower the pH and the more soluble the calcium and phosphate. Individual commercially available amino acid solutions vary significantly with respect to pH lowering potential and consequent calcium phosphate compatibility; consult product specific labeling for additional information.

Vesicant; ensure proper needle or catheter placement prior to and during IV infusion. Avoid extravasation.

Early/acute calcium extravasation: If acute extravasation occurs, stop infusion immediately and disconnect (leave needle/cannula in place); gently aspirate extravasated solution (do NOT flush the line); initiate hyaluronidase antidote (see Management of Drug Extravasations for more details); remove needle/cannula; apply dry cold compresses; elevate extremity (Ref).

Delayed calcium extravasation: If delayed extravasation suspected, closely monitor site; most calcifications spontaneously resolve. However, if a severe manifestation of calcinosis cutis occurs, may initiate sodium thiosulfate antidote (See Management of Drug Extravasations for more details) (Ref).

Use: Labeled Indications

Hypocalcemia, acute: Treatment of acute symptomatic hypocalcemia.

Use: Off-Label: Adult

Beta-blocker overdose; Calcium channel blocker overdose; Calcium replacement, during CRRT with citrate-based regional anticoagulation; Hydrofluoric acid exposure; Hyperkalemia, severe/emergent; Hypermagnesemia-associated cardiac arrest

Medication Safety Issues
Sound-alike/look-alike issues:

Calcium chloride may be confused with calcium gluconate

Administration issues:

Calcium chloride may be confused with calcium gluconate.

Confusion with the different intravenous salt forms of calcium has occurred. There is a threefold difference in the primary cation concentration between calcium chloride (in which 1 g = 14 mEq [270 mg] of elemental Ca++) and calcium gluconate (in which 1 g = 4.65 mEq [93 mg] of elemental Ca++).

Prescribers should specify which salt form is desired. To prevent medication errors, dosages should be expressed either as mg or grams of the salt form for most indications. Dosages expressed as mEq may be used for nutrition.

Metabolism/Transport Effects

None known.

Drug Interactions

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.

Baloxavir Marboxil: Polyvalent Cation Containing Products may decrease the serum concentration of Baloxavir Marboxil. Risk X: Avoid combination

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

CefTRIAXone: Calcium Salts (Intravenous) may enhance the adverse/toxic effect of CefTRIAXone. Ceftriaxone binds to calcium forming an insoluble precipitate. Management: Use of ceftriaxone is contraindicated in neonates (28 days of age or younger) who require (or are expected to require) treatment with IV calcium-containing solutions. In older patients, flush lines with compatible fluid between administration. Risk D: Consider therapy modification

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

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

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

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

Thiazide and Thiazide-Like Diuretics: May increase the serum concentration of Calcium Salts. Risk C: Monitor therapy

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

Pregnancy Considerations

Calcium crosses the placenta. 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).

Information related to use as an antidote in pregnancy is limited. In general, medications used as antidotes should take into consideration the health and prognosis of the mother; antidotes should be administered to pregnant women if there is a clear indication for use and should not be withheld because of fears of teratogenicity (Bailey 2003). Medications used for the treatment of cardiac arrest in pregnancy are the same as in the nonpregnant woman. Doses and indications should follow current Advanced Cardiovascular Life Support guidelines. Appropriate medications should not be withheld due to concerns of fetal teratogenicity (AHA [Jeejeebhoy 2015]).

Breastfeeding Considerations

Calcium is excreted 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).

Monitoring Parameters

Serum calcium and ionized calcium; serum calcium every 4 hours in patients with renal impairment; albumin; serum phosphate; magnesium (to facilitate calcium repletion); ECG when appropriate. Monitor infusion site.

Calcium channel blocker overdose, beta-blocker overdose (off-label uses): Monitor hemodynamic response; monitor serum ionized calcium levels every 30 minutes initially then every 2 hours and maintain ionized calcium ~2 times the ULN; avoid severe hypercalcemia (ionized calcium levels >2 times ULN) (Kerns 2007).

Reference Range

Serum total calcium: 8.4 to 10.2 mg/dL (2.1 to 2.55 mmol/L). Note: 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.

Serum ionized calcium: 4.48 to 5.32 mg/dL (1.12 to 1.33 mmol/L) (Zaloga 1992)

In low albumin states, the corrected total serum calcium may be estimated by the following equation (assuming a normal albumin of 4 g/dL [40 g/L]).

Corrected total calcium (mg/dL) = measured total calcium (mg/mL) + 0.8 [4 - measured serum albumin (g/dL)]

or

Corrected total calcium (mmol/L) = measured total calcium (mmol/L) + 0.02 [40-measured serum albumin (g/L)]

Mechanism of Action

Moderates nerve and muscle performance via action potential excitation threshold regulation.

In hydrofluoric acid (hydrogen fluoride) exposures, calcium chloride provides an exogenous source of calcium which can bind fluoride ions as well as treat and prevent complications secondary to hypocalcemia; intra-arterial administration can reduce the penetration of the fluoride ion into tissues and prevent or reduce tissue destruction and pain (Vance 1986; Wu 2010).

Pharmacokinetics (Adult Data Unless Noted)

Distribution: Primarily in skeleton (99%).

Protein binding: ~40%, primarily to albumin.

Excretion: Primarily feces (80% as insoluble calcium salts); urine (20%) (IOM 2011).

Brand Names: International
International Brand Names by Country
For country code abbreviations (show table)

  • (AR) Argentina: Cloruro de calcio;
  • (AT) Austria: Calciumchlorid fresenius kabi aus;
  • (BE) Belgium: Calciclo;
  • (CL) Chile: Cloruro de calcio;
  • (CZ) Czech Republic: Calcium chloratum;
  • (DE) Germany: Calciumchlorid | Calciumchlorid Baxter;
  • (DO) Dominican Republic: Cloruro de calcio;
  • (EE) Estonia: Calcii chloridum;
  • (ES) Spain: Cloruro calcico Braun;
  • (FR) France: Calcium cooper | Chlorure de calacium cooper | Chlorure de calcium aguettant;
  • (HU) Hungary: Calcium chloratum;
  • (IN) India: Nelcium;
  • (IT) Italy: Calcio Cloruro | Calcio cloruro monico;
  • (JP) Japan: Calcium chloride kobayashi | Calcium chloride merck hoei | Calcium chloride nipro | Chlocalin | Encal hikari | Encal otsuka;
  • (KR) Korea, Republic of: Huons Calcium Chloride | Jw 3% calcium chloride;
  • (LT) Lithuania: Calcium chloratum | Calcium chloridum | Calciumchlorid;
  • (LV) Latvia: Calcii chloridum | Calcium chloratum;
  • (NO) Norway: Calciumklorid;
  • (RU) Russian Federation: Calcium chloratum;
  • (SE) Sweden: Calrecia | Kalciumklorid APL;
  • (SK) Slovakia: Calcium chloratum;
  • (UA) Ukraine: Calcium chloratum;
  • (UY) Uruguay: Cloruro de calcio
  1. Aluminum in large and small volume parenterals used in total parenteral nutrition. Fed Regist. 2002;67(244):77792-77793. To be codified at 21 CFR §201.323.
  2. Ariyan CE, Sosa JA. Assessment and Management of Patients With Abnormal Calcium. Crit Care Med. 2004;32(4)(suppl):146-154. [PubMed 15064673]
  3. Arroyo AM, Kao LW. Calcium Channel Blocker Toxicity. Pediatr Emer Care. 2009;25(8):532-541. [PubMed 19687715]
  4. Bailey B. Are There Teratogenic Risks Associated With Antidotes Used in the Acute Management of Poisoned Pregnant Women? Birth Defects Res A Clin Mol Teratol. 2003;67(2):133-140. [PubMed 12769509]
  5. Bilezikian JP. Management of Acute Hypercalcemia. N Engl J Med. 1992;326(18):1196-1215. [PubMed 1532633]
  6. Bilezikian JP, Brandi ML, Cusano NE, et al. Management of hypoparathyroidism: present and future. J Clin Endocrinol Metab. 2016;101(6):2313-2324. doi:10.1210/jc.2015-3910 [PubMed 26938200]
  7. Binder LS. Acute Arthropod Envenomation: Incidence, Clinical Features, and Management. Med Toxicol Adverse Drug Exp. 1989;4(3):163-173. [PubMed 2664428]
  8. Burry LD, Tung DD, Hallett D, et al. Regional citrate anticoagulation for PrismaFlex continuous renal replacement therapy. Ann Pharmacother. 2009;43(9):1419-1425. doi:10.1345/aph.1M182 [PubMed 19690224]
  9. Brimacombe JR, Scully M, Swainston R. Propranolol overdose--a dramatic response to calcium chloride. Med J Aust. 1991;155(4):267-268. doi:10.5694/j.1326-5377.1991.tb142238.x [PubMed 1875846]
  10. Brubacher JR. Beta-adrenergic antagonists. In: Nelson LS, Howland MA, Lewin NA, Smith SW, Hoffman RS, eds. Goldfrank's Toxicologic Emergencies. 11th ed. McGraw Hill; 2019.
  11. Calcium chloride [prescribing information]. Shirley, NY: American Regent; July 2017.
  12. Calcium chloride [prescribing information]. Lake Forest, IL: Hospira, Inc; May 2023.
  13. Calcium Chloride (Dihydrate) [prescribing information]. Glendale Heights, IL: Medefil Inc; August 2020.
  14. Carlon GC, Howland WS, Goldiner PL, Kahn RC, Bertoni G, Turnbull AD. Adverse effects of calcium administration. Report of two cases. Arch Surg. 1978;113(7):882-885. doi:10.1001/archsurg.1978.01370190104021 [PubMed 678101]
  15. Chin RL, Garmel GM, Harter PM. Development of Ventricular Fibrillation After Intravenous Calcium Chloride Administration in a Patient With Supraventricular Tachycardia. Ann Emerg Med. 1995;25(3):416-419. [PubMed 7864486]
  16. Clase CM, Carrero JJ, Ellison DH, et al; Conference Participants. Potassium homeostasis and management of dyskalemia in kidney diseases: conclusions from a Kidney Disease: Improving Global Outcomes (KDIGO) Controversies Conference. Kidney Int. 2020;97(1):42-61. doi:10.1016/j.kint.2019.09.018 [PubMed 31706619]
  17. Dart RC, Goldfrank LR, Erstad BL, et al. Expert consensus guidelines for stocking of antidotes in hospitals that provide emergency care. Ann Emerg Med. 2018;71(3):314-325.e1. doi:10.1016/j.annemergmed.2017.05.021 [PubMed 28669553]
  18. Department Health & Human Services, Food Drug Administration. Aluminum in Large and Small Volume Parenterals Used in Total Parenteral Nutrition. Federal Register. 2000;65(17):4103-4111.
  19. DeWitt CR, Walsman JC. Pharmacology, Pathophysiology and Management of Calcium Channel Blocker and Beta-Blocker Toxicity. Toxicol Rev. 2004;23(4):223-238. [PubMed 15898828]
  20. Dickerson RN. Treatment of Hypocalcemia in Critical Illness - Part 1. Nutrition. 2007;23(4):358-361. [PubMed 17400132]
  21. Dickerson RN. Treatment of Hypocalcemia in Critical Illness - Part 2. Nutrition. 2007;23(5):436-437. [PubMed 17360159]
  22. Ehsani AH, Abedini R, Ghiasi M, Hoseini MS. Calcinosis cutis complicating liver transplantation. Dermatol Online J. 2006;12(7):23. [PubMed 17459309]
  23. Fong J, Khan A. Hypocalcemia: updates in diagnosis and management for primary care. Can Fam Physician. 2012;58(2):158-162. [PubMed 22439169]
  24. French S, Subauste J, Geraci S. Calcium abnormalities in hospitalized patients. Southern Med J. 2012;105(4):231-237. [PubMed 22475676]
  25. Goltzman D. Treatment of hypocalcemia. Post TW, ed. UpToDate. Waltham, MA: UpToDate Inc. http://www.uptodate.com. Accessed March 9, 2022.
  26. Greco RJ, Hartford CE, Haith LR Jr, Patton ML. Hydrofluoric acid-induced hypocalcemia. J Trauma. 1988;28(11):1593-1596. doi:10.1097/00005373-198811000-00015 [PubMed 3184225]
  27. Hegenbarth MA and the American Academy of Pediatrics Committee on Drugs. Preparing for Pediatric Emergencies: Drugs to Consider. Pediatrics. 2008;121(2):433-443. [PubMed 18245435]
  28. Henry M, Kay MM, Viccellio P. Cardiogenic shock associated with calcium-channel and beta blockers: reversal with intravenous calcium chloride. Am J Emerg Med. 1985;3(4):334-336. doi:10.1016/0735-6757(85)90060-9 [PubMed 2860911]
  29. Howarth DM, Dawson AH, Smith AJ, et al. Calcium Channel Blocking Drug Overdose: An Australian Series. Hum Exp Toxicol. 1994;13(3):161-166. [PubMed 7909677]
  30. Hurst S, McMillan M. Innovative solutions in critical care units: extravasation guidelines. Dimens Crit Care Nurs. 2004;23(3):125-128. [PubMed 15192356]
  31. IOM (Institute of Medicine). Dietary Reference Intakes for Calcium and Vitamin D. The National Academies Press; 2011.
  32. Isbister GK. Continuous Calcium Chloride Infusion for Massive Nifedipine Overdose. Emerg Med J. 2002;19(4):355-357. [PubMed 12101159]
  33. Jang DH. Calcium channel blockers. In: Nelson LS, Howland MA, Lewin NA, Smith SW, Hoffman RS, eds. Goldfrank's Toxicologic Emergencies. 11th ed. McGraw Hill; 2019.
  34. Jeejeebhoy FM, Zelop CM, Lipman S, et al; American Heart Association Emergency Cardiovascular Care Committee, Council on Cardiopulmonary, Critical Care, Perioperative and Resuscitation, Council on Cardiovascular Diseases in the Young, and Council on Clinical Cardiology. Cardiac Arrest in Pregnancy: A Scientific Statement From the American Heart Association. Circulation. 2015;132(18):1747-1773. doi:10.1161/CIR.0000000000000300 [PubMed 26443610]
  35. Jones JL. Metoprolol overdose. Ann Emerg Med. 1982;11(2):114-115. doi:10.1016/s0196-0644(82)80324-7 [PubMed 7137684]
  36. Kerns W 2nd. Management of beta-adrenergic blocker and calcium channel antagonist toxicity. Emerg Med Clin North Am. 2007;25(2):309-331. [PubMed 17482022]
  37. Kirwan CJ, Hutchison R, Ghabina S, et al. Implementation of a simplified regional citrate anticoagulation protocol for post-dilution continuous hemofiltration using a bicarbonate buffered, calcium containing replacement solution. Blood Purif. 2016;42(4):349-355. doi:10.1159/000452755 [PubMed 27866200]
  38. Kiser TH, Barber GR, Robinson A. Managing the intravenous calcium shortage: evaluation of calcium chloride stability in 0.9% sodium chloride and dextrose 5% water polyvinyl chloride bags. Hosp Pharm. 2012;47(1):27-30. doi:10.1310/hpj4701-27 [PubMed 32180591]
  39. Kleinman ME, Chameides L, Schexnayder SM, et al. Part 14: Pediatric Advanced Life Support: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2010;122(18)(suppl 3):876-908. [PubMed 20956230]
  40. Kusumoto FM, Schoenfeld MH, Barrett C, et al. 2018 ACC/AHA/HRS guideline on the evaluation and management of patients with bradycardia and cardiac conduction delay: a report of the American College of Cardiology/American Heart Association task force on clinical practice guidelines and the Heart Rhythm Society. Circulation. 2019;140(8):e382-e482. doi:10.1161/CIR.0000000000000628 [PubMed 30586772]
  41. Lam YM, Tse HF, Lau CP. Delayed Asystolic Cardiac Arrest After Diltiazem Overdose: Resuscitation With High Dose Intravenous Calcium. Chest. 2001;119(4):1280-1282. [PubMed 11296202]
  42. Luscher TF, Noll G, Sturmer T. Calcium Gluconate in Severe Verapamil Intoxication. N Engl J Med. 1994;330(10):718-720. [PubMed 8107735]
  43. MacCara ME. Extravasation: a hazard of intravenous therapy. Drug Intell Clin Pharm. 1983;17(10):713-717. [PubMed 6628223]
  44. Martin TJ, Kang Y, Robertson KM, et al. Ionization and Hemodynamic Effects of Calcium Chloride and Calcium Gluconate in the Absence of Hepatic Function. Anesthesiology. 1990;73(1):62-65. [PubMed 2360741]
  45. McIvor ME. Acute Fluoride Toxicity. Pathophysiology and Management. Drug Saf. 1990;5(2):79-84. [PubMed 2182050]
  46. Mirtallo J, Canada T, Johnson D, et al. Safe Practices for Parenteral Nutrition. JPEN J Parenter Enteral Nutr. 2004;28(6):S39-S70. [PubMed 15568296]
  47. Mokhlesi B, Leikin JB, Murray P, et al. Adult Toxicology in Critical Care: Part II: Specific Poisonings. Chest. 2003;123(3):897-922. [PubMed 12628894]
  48. Mount DB. Treatment and prevention of hyperkalemia in adults. Post TW, ed. UpToDate. Waltham, MA: UpToDate Inc. http://www.uptodate.com. Accessed November 9, 2021.
  49. Panchal AR, Bartos JA, Cabañas JG, et al; Adult basic and advanced life support writing group. Part 3: adult basic and advanced life support: 2020 American Heart Association guidelines for cardiopulmonary resuscitation and emergency cardiovascular care. Circulation. 2020;142(16)(suppl 2):S366-S468. doi:10.1161/CIR.0000000000000916 [PubMed 33081529]
  50. Pearigen PD, Benowitz NL. Poisoning Due to Calcium Antagonists. Experience With Verapamil, Diltiazem, and Nifedipine. Drug Saf. 1991;6(6):408-430. [PubMed 1793522]
  51. Perkins CM. Serious verapamil poisoning: treatment with intravenous calcium gluconate. Br Med J. 1978;2(6145):1127. [PubMed 709264]
  52. Pertoldi F, D'Orlando L, Mercante WP. Electromechanical dissociation 48 hours after atenolol overdose: usefulness of calcium chloride. Ann Emerg Med. 1998;31(6):777-781. [PubMed 9624322]
  53. Ramoska EA, Spiller HA, Winter M, Borys D. A one-year evaluation of calcium channel blocker overdoses: toxicity and treatment. Ann Emerg Med. 1993;22(2):196-200. [PubMed 8427431]
  54. Reynolds PM, MacLaren R, Mueller SW, Fish DN, Kiser TH. Management of extravasation injuries: a focused evaluation of noncytotoxic medications. Pharmacotherapy. 2014;34(6):617-632. doi:10.1002/phar.1396 [PubMed 24420913]
  55. Salhanick SD, Shannon MW. Management of Calcium Channel Antagonist Overdose. Drug Saf. 2003;26(2):65-79. [PubMed 12534324]
  56. Schneider AG, Journois D, Rimmelé T. Complications of regional citrate anticoagulation: accumulation or overload? Crit Care. 2017;21(1):281. doi:10.1186/s13054-017-1880-1 [PubMed 29151020]
  57. Shepherd G. Treatment of Poisoning Caused by β-adrenergic and Calcium-Channel Blockers. Am J Health-Syst Pharm. 2006;63(19):1828-1835. [PubMed 16990629]
  58. Slattery A, King WD, Nichols M, et al. Hypercalcemia Following Damp-Rid™ Ingestion. Clin Toxicol. 1995;33(5):487.
  59. Smith SW, Howland MA. Calcium. In: Nelson LS, Howland MA, Lewin NA, Smith SW, Hoffman RS, eds. Goldfrank's Toxicologic Emergencies. 11th ed. McGraw Hill; 2019.
  60. Smolders EJ, Benoist GE, Smit CCH, Ter Horst P. An update on extravasation: basic knowledge for clinical pharmacists. Eur J Hosp Pharm. 2020;28(3):165–167. doi:10.1136/ejhpharm-2019-002152 [PubMed 32341081]
  61. St-Onge M, Anseeuw K, Cantrell FL, et al. Experts consensus recommendations for the management of calcium channel blocker poisoning in adults. Crit Care Med. 2017;45(3):e306-e315. doi:10.1097/CCM.0000000000002087 [PubMed 27749343]
  62. Stefanos SS, Kiser TH, MacLaren R, Mueller SW, Reynolds PM. Management of noncytotoxic extravasation injuries: a focused update on medications, treatment strategies, and peripheral administration of vasopressors and hypertonic saline. Pharmacotherapy. 2023;43(4):321-337. doi:10.1002/phar.2794 [PubMed 36938775]
  63. Su MK. Hyrdofluoric acid and fluorides. In: Nelson LS, Howland MA, Lewin NA, Smith SW, Hoffman RS, eds. Goldfrank's Toxicologic Emergencies. 11th ed. McGraw Hill; 2019.
  64. Tolwani AJ, Prendergast MB, Speer RR, Stofan BS, Wille KM. A practical citrate anticoagulation continuous venovenous hemodiafiltration protocol for metabolic control and high solute clearance. Clin J Am Soc Nephrol. 2006;1(1):79-87. doi:10.2215/CJN.00040505 [PubMed 17699194]
  65. Turner J, Gittoes N, Selby P; Society for Endocrinology Clinical Committee. Society for Endocrinology emergency endocrine guidance: emergency management of acute hypocalcaemia in adult patients. Endocr Connect. 2019;8(6):X1. doi:10.1530/EC-16-0056 [PubMed 32022081]
  66. Turner J, Gittoes N, Selby P; Society for Endocrinology Clinical Committee. Society for Endocrinology endocrine emergency guidance: emergency management of acute hypocalcaemia in adult patients. Endocr Connect. 2016;5(5):G7-G8. doi:10.1530/EC-16-0056 [PubMed 27935815]
  67. Vallentin MF, Granfeldt A, Meilandt C, et al. Effect of intravenous or intraosseous calcium vs saline on return of spontaneous circulation in adults with out-of-hospital cardiac arrest: a randomized clinical trial. JAMA. 2021;326(22):2268-2276. doi:10.1001/jama.2021.20929 [PubMed 34847226]
  68. Vance MV, Curry SC, Kunkel DB, Ryan PJ, Ruggeri SB. Digital hydrofluoric acid burns: treatment with intraarterial calcium infusion. Ann Emerg Med. 1986;15(8):890-896. doi:10.1016/s0196-0644(86)80670-9 [PubMed 3740574]
  69. Vanden Hoek TL, Morrison LJ, Shuster M, et al. Part 12: cardiac arrest in special situations: 2010 American Heart Association guidelines for cardiopulmonary resuscitation and emergency cardiovascular care. Circulation. 2010;122(18)(suppl 3):S829-S861. doi:10.1161/CIRCULATIONAHA.110.971069 [PubMed 20956228]
  70. Vohra R, Velez LI, Rivera W, Benitez FL, Delaney KA. Recurrent life-threatening ventricular dysrhythmias associated with acute hydrofluoric acid ingestion: observations in one case and implications for mechanism of toxicity. Clin Toxicol (Phila). 2008;46(1):79-84. doi:10.1080/15563650701639097 [PubMed 17906993]
  71. Worthley LI and Phillips PJ. Intravenous calcium salts. Lancet. 1980;2(8186):149. [PubMed 6105319]
  72. Wu ML, Deng JF, Fan JS. Survival after hypocalcemia, hypomagnesemia, hypokalemia and cardiac arrest following mild hydrofluoric acid burn. Clin Toxicol (Phila). 2010;48(9):953-955. doi:10.3109/15563650.2010.533676 [PubMed 21171855]
  73. Zaloga GP. Hypocalcemia in critically ill patients. Crit Care Med. 1992;20(2):251-262. [PubMed 1737459]
  74. Zenk KE. Management of intravenous extravasations. Infusion. 1981;5(4):77-79.
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