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Pronunciation:

(KAL see um KAR bun ate)

U.S. Brand Names:

Alcalak [OTC]; Alka-Mints® [OTC]; Amitone® [OTC]; Calcarb 600 [OTC]; Calci-Chew® [OTC]; Calci-Mix®[OTC]; Cal-Gest [OTC]; Cal-Mint [OTC]; Caltrate® 600 [OTC]; Chooz® [OTC]; Florical® [OTC]; Mylanta® Children's [OTC]; Nephro-Calci® [OTC]; Os-Cal® 500 [OTC]; Oysco 500 [OTC]; Oyst-Cal 500 [OTC]; Titralac ™ [OTC]; Titralac™ Extra Strength [OTC]; Tums® [OTC]; Tums® 500 [OTC]; Tums® E-X [OTC]; Tums® Extra Strength Sugar Free [OTC]; Tums® Smooth Dissolve [OTC]; Tums® Ultra [OTC]

Generic Available:

Yes: Excludes capsule

Canadian Brand Names:

Apo-Cal®; Calcite-500; Caltrate®; Os-Cal®

Use:

As an antacid, and treatment and prevention of calcium deficiency or hyperphosphatemia (eg, osteoporosis, osteomalacia, mild/moderate renal insufficiency, hypoparathyroidism, postmenopausal osteoporosis, rickets); has been used to bind phosphate

Pregnancy Implications:

Available evidence suggests safe use during pregnancy and breast-feeding.

Contraindications:

Hypercalcemia, renal calculi, hypophosphatemia

Warnings/Precautions:

Calcium carbonate absorption is impaired in achlorhydria (common in elderly - use alternate salt, administer with food); administration is followed by increased gastric acid secretion within 2 hours of administration; while hypercalcemia and hypercalciuria may result when therapeutic replacement amounts are given for prolonged periods, they are most likely to occur in hypoparathyroid patients receiving high doses of vitamin D

Adverse Reactions:

Well tolerated

1% to 10%:

Central nervous system: Headache

Endocrine & metabolic: Hypophosphatemia, hypercalcemia

Gastrointestinal: Constipation, laxative effect, acid rebound, nausea, vomiting, anorexia, abdominal pain, xerostomia, flatulence

Miscellaneous: Milk-alkali syndrome with very high, chronic dosing and/or renal failure (headache, nausea, irritability, and weakness or alkalosis, hypercalcemia, renal impairment)

Overdosage/Toxicology:

Acute single ingestions of calcium salts may produce mild gastrointestinal distress, but hypercalcemia or other toxic manifestations are extremely unlikely

Treatment is supportive

Drug Interactions:

Calcium channel blockers (eg, verapamil) effects may be diminished; monitor response.

Levothyroxine: Calcium carbonate (and possibly other calcium salts) may decrease T4 absorption; separate dose from levothyroxine by at least 4 hours

Polystyrene sulfonate: Potassium-binding ability is reduced; avoid concurrent use.

Tetracycline, atenolol (and potentially other beta-blockers), iron, quinolone antibiotics, alendronate, sodium fluoride, and zinc absorption is significantly decreased; space administration times.

Thiazide diuretics can cause hypercalcemia; monitor response.

May potentiate digoxin toxicity. High doses of calcium with thiazide diuretics may result in milk-alkali syndrome and hypercalcemia.

Ethanol/Nutrition/Herb Interactions:

Ethanol: Avoid ethanol (may increase risk of osteoporosis).

Food: Food may increase calcium absorption. Calcium may decrease iron absorption. Bran, foods high in oxalates, or whole grain cereals may decrease calcium absorption.

Stability:

Admixture incompatibilities include carbonates, phosphates, sulfates, tartrates

Mechanism of Action:

As dietary supplement, used to prevent or treat negative calcium balance; in osteoporosis, it helps to prevent or decrease the rate of bone loss. The calcium in calcium salts moderates nerve and muscle performance and allows normal cardiac function. Also used to treat hyperphosphatemia in patients with advanced renal insufficiency by combining with dietary phosphate to form insoluble calcium phosphate, which is excreted in feces. Calcium salts as antacids neutralize gastric acidity resulting in increased gastric an duodenal bulb pH; they additionally inhibit proteolytic activity of peptic if the pH is increased >4 and increase lower esophageal sphincter tone.

Pharmacodynamics/Kinetics:

Absorption: Requires vitamin D; minimal unless chronic, high doses are given; calcium is absorbed in soluble, ionized form; solubility of calcium is increased in an acid environment

Distribution: Crosses placenta; enters breast milk

Excretion: Primarily feces (as unabsorbed calcium); urine (20%)

Dosage:

Oral (dosage is in terms of elemental calcium):

Dietary Reference Intake:

0-6 months: 210 mg/day

7-12 months: 270 mg/day

1-3 years: 500 mg/day

4-8 years: 800 mg/day

Adults, Male/Female:

9-18 years: 1300 mg/day

19-50 years: 1000 mg/day

51 years: 1200 mg/day

Female: Pregnancy: Same as for Adults, Male/Female

Female: Lactating: Same as for Adults, Male/Female

Hypocalcemia (dose depends on clinical condition and serum calcium level): Dose expressed in mg of elemental calcium

Neonates: 50-150 mg/kg/day in 4-6 divided doses; not to exceed 1 g/day

Children: 45-65 mg/kg/day in 4 divided doses

Adults: 1-2 g or more/day in 3-4 divided doses

Adults:

Dietary supplementation: 500 mg to 2 g divided 2-4 times/day

Antacid: Dosage based on acid-neutralizing capacity of specific product; generally, 1-2 tablets or 5-10 mL every 2 hours; maximum: 7000 mg calcium carbonate per 24 hours; specific product labeling should be consulted

Adults >51 years: Osteoporosis: 1200 mg/day

Dosing adjustment in renal impairment: Clcr<25 mL/minute: Dosage adjustments may be necessary depending on the serum calcium levels

Reference Range:

Serum calcium: 8.4-10.2 mg/dL: Monitor plasma calcium levels if using calcium salts as electrolyte supplements for deficiency

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 = total serum calcium + 0.8 (4.0 - measured serum albumin)

Test Interactions:

Increased calcium (S); decreased magnesium

Dietary Considerations:

As a dietary supplement, should be given with meals to increase absorption. May decrease iron absorption, so should be administered 1-2 hours before or after iron supplementation; limit intake of with bran, foods high in oxalates or whole grain cereals which may decrease calcium absorption.

Patient Education:

Oral: Follow instructions for dosing. Take with a full glass of water or juice 1-2 hours before any iron supplements and 1-3 hours after meals or other medications. Avoid alcohol, other antacids, caffeine, or other calcium supplements, unless approved by prescriber. You may experience constipation (increased exercise, fluids, fiber, or fruit may help) or dry mouth (sucking lozenges or hard candy may help). Report severe, unresolved GI disturbances and unusual emotional liability (mood swings). Pregnancy precaution: Inform prescriber if you are or intend to become pregnant.

Nursing Implications:

Monitor serum calcium levels

Additional Information:

20 mEq calcium/g; 400 mg elemental calcium/g calcium carbonate (40% elemental calcium)

Cardiovascular Considerations:

Hypercalcemia is evident on ECG by shortening of the QT interval and possibly lengthening of the PR interval. Hypocalcemia causes prolongation of the QT interval. This prolongation is due to lengthening of the ST segment; the T waves remain unchanged. However, in severe hypocalcemia, T waves may be inverted. Note that only hypocalcemia and hypothermia lengthen the ST segment without altering T-wave duration. Hypocalcemia may also present clinically with skeletal muscle spasm.

Dental Health: Effects on Dental Treatment:

Key adverse event(s) related to dental treatment: Xerostomia (normal salivary flow resumes upon discontinuation).

Dental Health: Vasoconstrictor/Local Anesthetic Precautions:

No information available to require special precautions

Mental Health: Effects on Mental Status:

May rarely produce irritability

Mental Health: Effects on Psychiatric Treatment:

None reported

Dosage Forms:

Capsule:

Calci-Mix®: 1250 mg [equivalent to elemental calcium 500 mg]

Florical®: 364 mg [equivalent to elemental calcium 145.6 mg; contains sodium fluoride 8.3 mg]

Powder: 1600 mg/teaspoonful (960 g)

Suspension, oral: 1250 mg/5 mL (5 mL, 500 mL) [equivalent to elemental calcium 500 mg/5 mL; mint flavor]

Tablet: 1250 mg [equivalent to elemental calcium 500 mg]; 1500 mg [equivalent to elemental calcium 600 mg]

Calcarb 600, Caltrate® 600, Nephro-Calci®: 1500 mg [equivalent to elemental calcium 600 mg]

Florical®: 364 mg [equivalent to elemental calcium 145.6 mg; contains sodium fluoride 8.3 mg]

Os-Cal® 500, Oysco 500, Oyst-Cal 500: 1250 mg [equivalent to elemental calcium 500 mg]

Tablet, chewable: 500 mg [equivalent to elemental calcium 200 mg]; 650 mg [equivalent to elemental calcium 260 mg]; 750 mg [equivalent to elemental calcium 300 mg]

Alcalak: 420 mg [equivalent to elemental calcium 168 mg]

Alka-Mints®: 850 mg [equivalent to elemental calcium 340 mg; assorted and spearmint flavors]

Amitone®: 420 mg [equivalent to elemental calcium 168 mg; spearmint flavor]

Cal-Gest: 500 mg [equivalent to elemental calcium 200 mg]

Calci-Chew®: 1250 mg [equivalent to elemental calcium 500 mg; cherry, lemon, and orange flavors]

Cal-Mint: 650 mg [equivalent to elemental calcium 260 mg; mint flavor]

Chooz®: 500 mg [equivalent to elemental calcium 200 mg; contains phenylalanine]

Mylanta® Children's: 400 mg [equivalent to elemental calcium 160 mg; bubble gum flavor]

Os-Cal® 500: 1250 mg [equivalent to elemental calcium 500 mg; Bavarian cream flavor]

Titralac™: 420 mg [equivalent to elemental calcium 168 mg; sugar free; mint flavor]

Titralac™ Extra Strength: 750 mg [equivalent to elemental calcium 300 mg; sugar free; mint flavor]

Tums®: 500 mg [equivalent to elemental calcium 200 mg; assorted fruit (contains tartrazine) and peppermint flavors]

Tums® E-X: 750 mg [equivalent to elemental calcium 300 mg; assorted fruit (contains tartrazine), fresh blend, tropical assorted fruit, wintergreen (contains tartrazine), and assorted berry flavors]

Tums® Extra Strength Sugar Free: 750 mg [equivalent to elemental calcium 300 mg; sugar free; contains phenylalanine <1 mg/tablet; orange cream flavor]

Tums® Smooth Dissolve: 750 mg [equivalent to elemental calcium 300 mg; assorted fruit (contains tartrazine) and peppermint flavors]

Tums® Ultra®: 1000 mg [equivalent to elemental calcium 400 mg; assorted mint, assorted berry, and tropical assorted berry (contains tartrazine) flavors]

International Brand Names:

Adcal® (GB); Additiva Calcium® (PL); Adiecal® (IT); Antacid® (RO); Apo-Cal® (CA); Bica® (AR); Bo-Ne-Ca® (TH); Cacit® (BE, GB, IE, IT, NL); Cal 500® (BD); Cal-Aid® (IN); Calbisan® (IT); Calcanate® (TH); Cal-Car® (IT); Calcefor Cap® (CL); Calcefor® (CL); Calci-Chew® (BE); Calcichew® (CZ, FI, GB, IE, LU); Calci-Chew® (NL); Calcichew® (RO); Calcidia® (FR); Calcidose® (FR); Calcidrink® (GB); Calcifar® (PL); Calcigamma® (DE); Calci-GRY® (DE); Calcii Carbonatis® (SI); Calcii-Min® (BG); Calcimagon® (DE); Calcimed® (DE, TR); Calcimore® (IL); Calcio 20 Madariaga® (ES); Calcio 500® (AR); Calcio 520 MG® (CL); Calcio 600 MK® (CO); Calcio Base Dupomar® (AR); Calcio Base Vent-3® (AR); Calcio Carbonato EG® (IT); Calcio Chiesi® (IT); Calciodie® (IT); Calcio GNR® (IT); Calcio MS Beta® (CL); Calcional® (AR); Calciopiù® (IT); Calcioral® (PT); Calcio Savio® (IT); Calcio Vannier® (AR); Calciprat® (FR); Calcitab® (PT); Calcite-500 (CA); Calcitridin® (DE); Calcitugg® (SE); Calcium AL® (DE); Calcium beta® (DE); Calcium Bruis® (NL); Calciumcarbonat® (DE); Calciumcarbonat-Dial® (AT); Calcium Carbonate® (CZ); Calciumcarbonat Fresenius® (CH, DE); Calciumcarbonat-Nefro® (DE); Calcium-Carbonat Salmon Pharma® (CH); Calciumcarbonat Sertürner® (DE); Calcium Dago-Steiner® (DE); Calcium dura® (DE); Calcium effervescens® (PL); Calcium Factor® (CL); Calcium® (GB, PL, TH); Calcium Genericon® (AT); Calcium Heumann® (DE); Calcium Hexal® (DE, RO); Calcium Nycomed® (CZ); Calcium Pharmavit® (HU); Calcium-Phosphatbinder Bichsel® (CH); Calcium-Sandoz® (IN); Calcium S.Med® (AT); Calcium Stada® (DE); Calcium Upsavit® (BG); Calcium Verla® (DE); calcium von ct® (DE); Calcivorin® (CL); Calcopan® (AR); Caldoral® (CO); Calma® (IT); Calperos® (CH, FR, PL); Calprimum® (FR); Calsan® (BR, MX); Calsuba® (ZA); Calsum® (TH); Cal-Sup® (NZ, SG); Caltab® (TH); Caltrate® (AU, BR, CA, CO, FR, IE, MX, PL, SG); Caosina® (ES); Caprimida® (CL); Carbocalc® (TH); Carbo® (IT); Carbonato Calcico® (CL); Carbonato de calcio® (CO); Carbosint® (IT); Carbotop® (IT); Cavirox® (AR); CC-Nefro® (DE); Cimascal® (ES); Citrical® (GB); Densical® (ES, FR); Dical D® (CL); Dreisacarb® (AT, DE); Elcal® (CL); Elcal Forte® (CL); Eucalcic® (FR); Fixical® (FR); Fortica® (TH); Frubiase® (BE); FructiCal® (PL); Hermes Biolectra Calcium® (BE); Idracal® (IT); Iroviton Calcium® (AT); Kalcidon® (FI, SE); Kalcijev karbonat® (HR, SI); Kalcij-karbonat® (HR); Kalcijum karbonat® (YU); Kalcipos® (FI, SE); Kalcitena® (SE); Levucal® (CL); Löscalcon® (DE); Lubical® (IT); Mastical® (ES); Maxicalc® (BR); Maxi-calc® (CH); Maxi-Kalz® (AT, CZ); Megacal® (CO); Metocal® (IT); Mylanta Pocket® (AR); Natecal® (BR, ES); Natecal D® (BR); Nefro-carbonat® (TR); Orocal® (MC); Os-Cal® (BR, CA); Ospur Ca® (DE); Osteo-Calcium® (BE); Osteocal® (CO, FR); Osteomin® (MX); Osteoplus® (DE); Ostocal® (BD); Oystercal® (JO, RO); Pérical® (FR); Pharcal® (TH); Pluscal® (AR); Prima-cal® (TH); Raffo-Ca® (AR); Recal® (IT); Remegel® (GB); Rubracal® (AR); Salicalcium® (IT); Sandocal® (BD); Savecal® (IT); Steocar® (BE); Tetesept Calcium® (AT); Titralac® (GB, NO, NZ); Top Calcium® (IT); Tums® (AR, AU, IL, PT, ZA); Tums E-X® (IL); Tums Ultra® (IL); Ultracalcium® (AR); Unical® (IT); Upsavit Calcium® (YU); Vicalvit® (PL); Vic® (IL); Vitacalcin® (PL); Vivural® (DE)

References

Bauwens SF, Drinka PJ, Boh LE, "Pathogenesis and Management of Primary Osteoporosis,"Clin Pharm, 1986, 5:639-59.

"Dietary Reference Intakes for Calcium, Phosphorus, Magnesium, Vitamin D, and Fluoride. Standing Committee on the Scientific Evaluation of Dietary Reference Intakes, Food and Nutrition Board, Institute of Medicine," National Academy of Sciences, Washington, DC: National Academy Press, 1997. Available at: http://www.nap.edu.

Heaney RP, Recker RR, and Saville PD, "Menopausal Changes in Calcium Balance Performance,"J Lab Clin Med, 1978, 92(6):953-63.

Mokhlesi B, Leikin JB, Murray P, et al, "Adult Toxicology in Critical Care: Part II: Specific Poisonings,"Chest, 2003, 123(3):897-922.

NIH Consensus Conference, "Optimal Calcium Intake,"JAMA, 1994, 272(24):1942-8.

Recker RR, "Calcium Absorption and Achlorhydria,"N Engl J Med, 1985, 313(2):70-3.

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