Version May 2024
Note: Syrup is a hyperosmolar solution.
Adequate intake (AI): Note: Recommended intake from dietary sources (eg, breast milk, formula).
Neonates: Dosage expressed as elemental calcium: Oral: 200 mg/day; requirements may vary on prematurity, postnatal age, and other clinical factors; serum calcium concentrations should be monitored closely to determine patient-specific needs (IOM 2011).
Enteral nutrition, maintenance requirement (dietary intake; formula, breast milk): Limited data available:
Preterm neonates, birth weight <2,000 g: Dosage expressed as elemental calcium: Oral: 150 to 220 mg/kg/day (AAP [Abrams 2013]).
Hypocalcemia, asymptomatic: Limited data available: Preterm and term neonates: Dosage expressed as elemental calcium: Oral: 50 to 75 mg/kg/day in 4 to 6 divided doses (Koo 2015).
Rickets, treatment: Limited data available: Note: Treatment should also include adequate vitamin D supplementation (AAP [Golden 2014]; Munns 2016).
Preterm and term neonates: Dose expressed as elemental calcium: Oral: Initial: 20 mg/kg/day, increased as tolerated to usual range of 60 to 70 mg/kg/day, usually administered in 4 to 6 divided doses; maximum daily dose: 80 mg/kg/day (AAP [Abrams 2013]; Koo 2015). Alternatively, 30 to 75 mg/kg/day in 3 divided doses with initial doses at higher end of range and then titrated downward over 2 to 4 weeks has also been recommended (Balasubramanian 2013; Misra 2008).
Dosing adjustment in renal impairment: 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.
Calcium dietary supplement: Dosage below based on product containing: 1.8 g calcium glubionate per 5 mL (115 mg elemental calcium per 5 mL) (manufacturer's labeling):
Infants: Oral: 5 mL 5 times daily; may mix with juice or formula.
Children <4 years: Oral: 10 mL 3 times daily.
Children ≥4 years and Adolescents: Oral: 15 mL 3 times daily.
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).
Rickets, treatment: Limited data available: Note: Treatment should also include adequate vitamin D supplementation (AAP [Golden 2014]; Munns 2016).
Infants, Children, and Adolescents: Dose expressed as elemental calcium: Oral: 30 to 75 mg/kg/day in 3 divided doses; begin at higher end of range and titrate downward over 2 to 4 weeks (Misra 2008; Root 2020).
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.
No initial dosage adjustment necessary; subsequent doses should be guided by serum calcium concentrations.
(For additional information see "Calcium glubionate: Drug information")
Dietary supplement: Oral: Note: Each 5 mL contains elemental calcium 115 mg: 15 mL 3 times daily or 15 mL 4 times daily (pregnancy/lactating).
The following adverse drug reactions and incidences are derived from product labeling unless otherwise specified.
Frequency not defined. Symptoms reported with hypercalcemia.
Endocrine & metabolic: Increased thirst
Gastrointestinal: Abdominal pain, anorexia, constipation, nausea, vomiting, xerostomia
Renal: Polyuria
Concerns related to adverse effects:
• Gastrointestinal effects: Constipation, bloating, and gas are common with calcium supplements (especially carbonate salt).
Disease-related concerns:
• Achlorhydria: Calcium absorption is impaired in achlorhydria; common in elderly, use an alternate salt (eg, citrate) and administer with food.
• 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.
Concurrent drug therapy issues:
• Minerals/other oral drugs: Calcium administration interferes with absorption of some minerals and drugs; use with caution.
• Vitamin D: It is recommended to concomitantly administer vitamin D for optimal calcium absorption.
Other warnings/precautions:
• Absorption: Taking calcium (≤500 mg) with food improves absorption.
• 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.
Oral syrup is hyperosmolar; in neonates, this may cause increased frequency of bowel movements (diarrhea) and GI intolerance (Koo 2015).
1 g calcium glubionate = elemental calcium 63.8 mg = calcium 3.2 mEq = calcium 1.6 mmol
May be product dependent
|
Calcium Salt |
Elemental Calcium (mg/1 g of salt form) |
Calcium (mEq/g) |
|---|---|---|
|
Calcium acetate |
253 |
12.7 |
|
Calcium carbonate |
400 |
20 |
|
Calcium chloride |
273 |
13.6 |
|
Calcium citrate |
211 |
10.5 |
|
Calcium glubionate |
63.8 |
3.2 |
|
Calcium gluconate |
93 |
4.65 |
|
Calcium lactate |
130 |
6.5 |
Oral: Administer with plenty of fluids with or following meals.
Take with a full glass of water or juice, 1-3 hours after meals and other medications, and 1-2 hours before any approved iron supplements.
Store at room temperature.
Dietary supplement (OTC product: FDA approved in infants, children, and adults); has also been used for treatment of hypocalcemia and rickets.
Calcium glubionate may be confused with calcium gluconate
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
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
Food may increase calcium absorption. Calcium may decrease iron absorption. Bran, foods high in oxalates, or whole grain cereals may decrease calcium absorption. Management: Administer preferably with food.
Should be taken before meals to enhance absorption. May decrease iron absorption so should be administered 1 to 2 hours before or after iron supplementation. Limit intake of bran, foods high in oxalates, or whole grain cereals which may decrease calcium absorption.
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.
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).
Serum calcium (ionized calcium preferred if available), phosphate, magnesium.
Note: Ranges may slightly vary by individual laboratories.
|
Age |
Serum Concentration | |
|---|---|---|
|
Calcium, total |
Cord blood |
9 to 11.5 mg/dL (SI: 2.3 to 2.9 mmol/L) |
|
Newborn 3 to 24 hours |
9 to 10.6 mg/dL (SI: 2.3 to 2.7 mmol/L) | |
|
Newborn 24 to 48 hours |
7 to 12 mg/dL (SI: 1.8 to 3 mmol/L) | |
|
4 to 7 days |
9 to 10.9 mg/dL (SI: 2.3 to 2.7 mmol/L) | |
|
Child |
8.8 to 10.8 mg/dL (SI: 2.2 to 2.7 mmol/L) | |
|
Adolescent to Adult |
8.4 to 10.2 mg/dL (SI: 2.1 to 2.6 mmol/L) | |
|
Calcium, ionized, whole blood |
Cord blood |
5 to 6 mg/dL |
|
Newborn 3 to 24 hours |
4.3 to 5.1 mg/dL | |
|
Newborn 24 to 48 hours |
4 to 4.7 mg/dL | |
|
≥2 days |
4.8 to 4.92 mg/dL (2.24 to 2.46 mEq/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 if ionized calcium is unavailable, the corrected total serum calcium may be estimated by this equation (assuming a normal albumin of 4 g/dL [SI: 40 g/L]):
Corrected total calcium (mg/dL) = measured serum calcium (mg/mL) + 0.8 (4 − measured serum albumin [g/dL])
As dietary supplement, used to prevent or treat negative calcium balance. The calcium in calcium salts moderates nerve and muscle performance and allows normal cardiac function.
Absorption: Minimal unless chronic, high doses; absorption predominantly in the duodenum and dependent on calcitriol and vitamin D; mean absorption of calcium intake varies with age (infants 60%, prepubertal children 28%, pubertal children 34%, adults 25%); during pregnancy, calcium absorption doubles; calcium is absorbed in soluble, ionized form; solubility of calcium is increased in an acid environment (IOM 2011); decreased absorption occurs in patients with achlorhydria, renal osteodystrophy, steatorrhea, or uremia
Distribution: Primarily in bones, teeth (IOM 2011)
Protein binding: ~40%, primarily to albumin (Wills 1971)
Excretion: Primarily feces (75%; as unabsorbed calcium); urine (22%) (IOM 2011)
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