Version May 2024
Note: Dosing units: All dosages are expressed as elemental zinc unless stated otherwise. Oral zinc sulfate contains ~23% elemental zinc.
Dietary supplement: Oral: 50 mg once daily.
Parenteral nutrition additive, maintenance requirement: Note: Individualize dose based on the patient's clinical condition, nutritional requirements, and the contribution of oral or enteral zinc intake.
Acute metabolic states: IV: Optimal dose not determined; monitor and replace as clinically indicated. Expert consensus recommendation suggest: 2.5 to 6.5 mg/day (Blaauw 2019).
Metabolically stable: IV: 3 to 5 mg/day (ASPEN 2020).
Replacement for small bowel fluid loss (metabolically stable): IV: Additional zinc replacement may be required for patients with high-output intestinal fistula, ostomy effluent, or severe diarrhea due to excessive zinc loss. Estimated loss ranges from up to an additional 12 mg zinc per L for small bowel fluid loss or an additional ~17 mg zinc per kg of stool or ileostomy output (Blaauw 2019; Jeejeebhoy 2009; Vanek 2012; manufacturer's labeling).
Zinc deficiency: Oral: Optimal dose not determined; some recommend daily doses of 2 to 3 times the zinc RDA for mild deficiency and 4 to 5 times the RDA for moderate to severe deficiency for 6 months (Saper 2009).
There are no dosage adjustments provided in the manufacturer's labeling; however, zinc and aluminum accumulation may occur in the setting of renal impairment.
There are no dosage adjustments provided in the manufacturer's labeling.
Refer to adult dosing.
(For additional information see "Zinc sulfate: Pediatric drug information")
Note: Dosages may be presented in units of mcg or mg; use caution to ensure correct units.
Parenteral nutrition, maintenance zinc requirement: Note: Higher doses may be needed (in some cases between 2 to 3 times the maintenance requirement) if impaired intestinal absorption or an excessive loss of zinc (eg, excessive, prolonged diarrhea; high-output intestinal fistula; burns) (AAP [Kleinman 2019]).
ASPEN recommendations: Infants, Children, and Adolescents:
3 to <10 kg: IV: Usual dose: 250 mcg elemental zinc/kg/day as an additive to parenteral nutrition solution (ASPEN 2020); reported range: 50 to 250 mcg elemental zinc/kg/day (ASPEN [Corkins 2015]; ASPEN [Mirtallo 2004]).
10 to 40 kg: IV: Usual dose: 50 mcg elemental zinc/kg/day as an additive to parenteral nutrition solution (ASPEN 2020); reported range: 50 to 125 mcg elemental zinc/kg/day; maximum daily dose: 5,000 mcg elemental zinc/day (ASPEN [Corkins 2015]; ASPEN [Mirtallo 2004]).
>40 kg: IV: 2,000 to 5,000 mcg elemental zinc/day as an additive to parenteral nutrition solution.
ESPGHAN recommendations: Infants, Children, and Adolescents:
Infants <3 months: IV: 250 mcg elemental zinc/kg/day as an additive to parenteral nutrition solution (ESPEN/ESPR/CSPEN [Domellöf 2018]).
Infants ≥3 months: IV: 100 mcg elemental zinc/kg/day as an additive to parenteral nutrition solution (ESPEN/ESPR/CSPEN [Domellöf 2018]).
Children and Adolescents: IV: 50 mcg elemental zinc/kg/day as an additive to parenteral nutrition solution; maximum daily dose: 5,000 mcg elemental zinc/day (ESPEN/ESPR/CSPEN [Domellöf 2018]).
Diarrhea, treatment; malnourished patient: Limited data available (WHO/UNICEF 2004): Note: Zinc should be started in conjunction with oral rehydration solutions at first sign of diarrhea; zinc therapy may shorten the duration and severity of episodes and prevent subsequent episodes (Bhandari 2008; Lazzerini 2016; Lukacik 2008; WHO/UNICEF 2004).
Infants <6 months: Oral: 10 mg elemental zinc once daily for 10 to 14 days (Bhandari 2008; Trivedi 2009; WHO/UNICEF 2004).
Infants ≥6 months and Children: Oral: 20 mg elemental zinc once daily for 10 to 14 days (Bhandari 2008; Trivedi 2009; WHO/UNICEF 2004). Note: Lower doses of 5 mg or 10 mg once daily for 14 days have shown noninferior efficacy and have been associated with less vomiting (Dhingra 2020).
Zinc deficiency; treatment: Limited data available:
Acquired (eg, secondary to cystic fibrosis, liver disease, sickle cell disease, short-bowel syndrome, intestinal failure): Infants, Children, and Adolescents: Oral: 0.5 to 2 mg elemental zinc/kg/day (AAP 1978; AAP [Kleinman 2019]; ASPEN [Corkins 2015]); dose should be individualized; required dose dependent upon multiple factors, which may include the following: age (younger patients, especially infants, have higher requirements), underlying cause of deficiency, physiologic status of other trace elements, enteral/parenteral nutrition intake (Borowitz 2002; Hotz 2001; Ubesie 2013).
Acrodermatitis enteropathica: Infants, Children, and Adolescents: Oral: 3 mg elemental zinc/kg/day; duration of therapy is typically life-long (Joyce 2020).
There are no dosage adjustments provided in the manufacturer's labeling; however, zinc and aluminum accumulation may occur in the setting of renal impairment.
There are no dosage adjustments provided in the manufacturer's labeling.
There are no adverse reactions listed in the manufacturer's labeling.
Injection: Hypersensitivity to zinc or any component of the formulation.
Disease-related concerns:
• Renal impairment: Use with caution in patients with renal impairment.
Concurrent drug therapy issues:
• Copper: Chronic administration of high-dose zinc may cause a decrease in enteral copper absorption and subsequent decreased copper deficiency (Kumar 2022; Marumo 2021; manufacturer's labeling).
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).
Strength of zinc sulfate injection is expressed as elemental zinc
Oral zinc sulfate is approximately 23% elemental zinc
Excipient information presented when available (limited, particularly for generics); consult specific product labeling. [DSC] = Discontinued product
Capsule, Oral:
Orazinc: 220 mg
Zinc-220: 220 mg [DSC]
Generic: 220 mg
Solution, Intravenous:
Generic: 1 mg/mL (10 mL); 3 mg/mL (10 mL); 5 mg/mL (5 mL)
Solution, Intravenous [preservative free]:
Generic: 1 mg/mL (10 mL); 3 mg/mL (10 mL); 5 mg/mL (5 mL)
Tablet, Oral:
Orazinc: 110 mg
Zinc 15: 66 mg
Generic: 220 mg
Yes
Capsules (Orazinc Oral)
220 (50 Zn) mg (per each): $0.08
Capsules (Zinc Sulfate Oral)
220 (50 Zn) mg (per each): $0.23
Solution (Zinc Sulfate Intravenous)
1 mg/mL (per mL): $1.68 - $3.68
3 mg/mL (per mL): $5.04 - $11.07
5 mg/mL (per mL): $8.40 - $18.42
Tablets (Orazinc Oral)
110 mg (per each): $0.04
Tablets (Zinc 15 Oral)
66 mg (per each): $0.02
Tablets (Zinc Sulfate Oral)
220 (50 Zn) 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.
Excipient information presented when available (limited, particularly for generics); consult specific product labeling.
Solution, Intravenous:
Micro-Zn: 1 mg/mL (10 mL); 5 mg/mL (10 mL)
Generic: 5 mg/mL (5 mL)
IV: Not for direct IV infusion; acidic pH of the solution may cause vein irritation, phlebitis, damage, or thrombosis; must be prepared and used as an admixture in parenteral nutrition solutions only.
Oral: Administer with food if GI upset occurs.
Parenteral: IV: Not for direct IV infusion; must be prepared and used as an admixture in parenteral nutrition solutions only.
Dietary supplement: Oral: Dietary supplement.
Parenteral nutrition additive, maintenance requirement: IV: Trace element added to parenteral nutrition to prevent deficiency.
ZnSO4 is an error-prone abbreviation (mistaken as morphine sulfate)
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.
Baloxavir Marboxil: Polyvalent Cation Containing Products may decrease the serum concentration of Baloxavir Marboxil. Risk X: Avoid combination
Bictegravir: Polyvalent Cation Containing Products may decrease the serum concentration of Bictegravir. Management: Administer bictegravir under fasting conditions at least 2 hours before or 6 hours after polyvalent cation containing products. Coadministration of bictegravir with or 2 hours after most polyvalent cation products is not recommended. 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
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
Dolutegravir: Zinc Salts may decrease the serum concentration of Dolutegravir. Management: Administer dolutegravir at least 2 hours before or 6 hours after oral zinc salts. Administer the dolutegravir/rilpivirine combination product at least 4 hours before or 6 hours after oral zinc salts. 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
Levonadifloxacin: Zinc Salts may decrease the serum concentration of Levonadifloxacin. Risk X: Avoid combination
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
Quinolones: Zinc Salts may decrease the serum concentration of Quinolones. Management: Give oral quinolones at several hours before (4 h for moxi- and sparfloxacin, 2 h for others) or after (8 h for moxi-, 6 h for cipro/dela-, 4 h for lome-, 3 h for gemi-, and 2 h for enox-, levo-, nor-, pe- or ofloxacin or nalidixic acid) oral zinc salts. 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
Tetracyclines: Zinc Salts may decrease the absorption of Tetracyclines. Only a concern when both products are administered orally. Management: Separate administration of oral tetracycline derivatives and oral zinc salts by at least 2 hours to minimize this interaction. 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
Avoid foods high in calcium or phosphorus.
Zinc crosses the placenta and can be measured in the cord blood and placenta. Fetal concentrations are regulated by the placenta (de Moraes 2011).
Zinc is found in breast milk; concentrations decrease over the first 6 months of lactation. Concentrations are generally not affected by dietary supplementation (IOM 2001).
May be taken with food if GI upset occurs.
Dietary reference intake (IOM 2001):
1 to 6 months: Adequate intake (AI): 2 mg elemental zinc/day.
7 to 12 months: Recommended dietary allowance (RDA): 3 mg elemental zinc/day.
1 to 3 years: RDA: 3 mg elemental zinc/day.
4 to 8 years: RDA: 5 mg elemental zinc/day.
9 to 13 years: RDA: 8 mg elemental zinc/day.
14 to 18 years: RDA:
Females: 9 mg elemental zinc/day.
Males: 11 mg elemental zinc/day.
Pregnancy: 12 mg elemental zinc/day.
Lactation: 13 mg elemental zinc/day.
Adults ≥19 years: RDA:
Females: 8 mg elemental zinc/day.
Males: 11 mg elemental zinc/day.
Pregnancy: 11 mg elemental zinc/day.
Lactation: 12 mg elemental zinc/day.
Periodic serum copper and serum zinc levels (patients on parenteral nutrition or chronic therapy); alkaline phosphatase, taste acuity, mental depression
Zinc, serum: 75 to 140 mcg/dL (11.5 to 21.4 mmol/L) (ABIM 2023). Note: Serum zinc concentrations are dependent on age and sex, and may fluctuate depending on time of blood draw, infection, hormone changes, and muscle catabolism; correlation with clinical signs and/or symptoms of zinc deficiency is recommended (NIH 2022).
Absorption: pH-dependent; enhanced at lower pH; (pH <3); impaired by food (Anderson 1998).
Distribution: Stored primarily in skeletal muscle and bone (IOM 2001).
Protein binding: Albumin and alpha 1-macroglobulin (Foote 1984).
Excretion: Feces and urine (IOM 2001).
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