Version May 2024
The FDA is warning health care providers to avoid using Hospira's unapproved potassium phosphates injectable product in pediatric patients because the aluminum exposure from this product is unsafe for this population. The FDA has requested that the manufacturer revise its labeling to reflect that use of the product in pediatric patients is not recommended because of the risk of aluminum toxicity.
In December 2022, the FDA issued a draft guidance for industry with a recommendation that the total allowable aluminum exposure from parenteral nutrition should not exceed 5 mcg/kg/day. Health care providers are advised to use an FDA-approved potassium phosphates injectable product with the aluminum content level considered acceptable for each patient based on age, weight, and recommended dose of phosphorus.
Further information may be found at https://www.fda.gov/drugs/drug-safety-and-availability/infants-risk-aluminum-toxicity-unapproved-potassium-phosphates-drug-product
Caution: The concomitant amount of potassium must be calculated into the total electrolyte content. Ensure that calculated dose does not provide excessive potassium; consider patient underlying conditions and all potassium sources. Each 1 mmol of phosphate provides ~1.5 mEq of potassium. With orders for IV phosphate, there is considerable confusion associated with the use of millimoles (mmol) versus milliequivalents (mEq) to express the phosphate requirement. The most reliable method of ordering IV phosphate is by millimoles, then specifying the potassium or sodium salt. Intravenous doses provided are as mmol of phosphate. Note: 1 mmol phosphate = 31 mg phosphorus; 1 mg phosphorus = 0.032 mmol phosphate.
Adequate intake (AI): Note: Recommended intake from dietary sources (eg, breast milk, formula). Neonate: 3.2 mmol/day (100 mg/day) (Ref).
Metabolic bone disease or rickets, prevention or treatment of hypophosphatemia: Preterm neonates: Oral: 0.32 to 0.64 mmol/kg/day in divided doses; may increase as needed to 1.28 to 1.6 mmol/kg/day in divided doses. Note: Parenteral solution for injection may be used enterally if oral dosage forms not appropriate (Ref).
Parenteral nutrition, maintenance phosphorus requirement: IV: 1 to 2 mmol/kg/day of phosphorus as an additive to parenteral nutrition solution (Ref). Note: Ca-P solubility issues may limit total daily dose provided in the TPN.
Caution: The concomitant amount of potassium must be calculated into the total electrolyte content. Ensure that calculated dose does not provide excessive potassium; consider patient underlying conditions and all potassium sources. Each 1 mmol of phosphate provides ~1.5 mEq of potassium. With orders for IV phosphate, there is considerable confusion associated with the use of millimoles (mmol) versus milliequivalents (mEq) to express the phosphate requirement. The most reliable method of ordering IV phosphate is by millimoles, then specifying the potassium or sodium salt. Note: 1 mmol phosphate = 31 mg phosphorus; 1 mg phosphorus = 0.032 mmol phosphate.
Hypophosphatemia, acute treatment: Repletion of severe hypophosphatemia should be treated with IV phosphate since large doses of oral phosphate may cause diarrhea and intestinal absorption may be unreliable. Reserve intermittent IV infusion for severe depletion situations; may require continuous cardiac monitoring depending on potassium administration rate. Guidelines differ based on degree of illness, need/use of TPN, and severity of hypophosphatemia. If hyperkalemia exists, consider phosphate replacement strategy without potassium (eg, sodium phosphates).
IV doses may be incorporated into the patient's maintenance IV fluids; intermittent IV infusion should be reserved for severe depletion situations; requires continuous cardiac monitoring. Note: Doses listed as mmol of phosphate.
Children and Adolescents: Note: Dose based on actual body weight; if patient is significantly above ideal body weight, consider using an adjusted body weight for dosing. The regimens below have only been studied in adult patients; however, many institutions have used them in children safely and successfully (Ref). Patients with severe renal impairment were excluded from adult phosphate supplement trials.
General replacement guidelines ( including ICU patients) (Ref): Note: The initial dose may be increased by 25% to 50% if the patient is symptomatic secondary to hypophosphatemia and lowered by 25% to 50% if the patient is hypercalcemic (Ref).
Low dose: 0.08 to 0.16 mmol/kg over 4 to 6 hours; use if serum phosphorus level 2.3 to 2.7 mg/dL.
Intermediate dose: 0.16 to 0.32 mmol/kg over 4 to 6 hours; use if serum phosphorus level 1.5 to 2.2 mg/dL.
High dose: 0.32 to 0.64 mmol/kg over 4 to 6 hours; use if serum phosphorus <1.5 mg/dL.
Patients receiving TPN (Ref):
Low dose: 0.16 mmol/kg over 4 to 6 hours; use if serum phosphorus level 2.3 to 3 mg/dL (0.73 to 0.96 mmol/L).
Intermediate dose: 0.32 mmol/kg over 4 to 6 hours; use if serum phosphorus level 1.6 to 2.2 mg/dL (0.51 to 0.72 mmol/L).
High dose: 0.64 mmol/kg over 8 to 12 hours; use if serum phosphorus <1.5 mg/dL (<0.5 mmol/L).
Critically ill adult trauma patients receiving TPN (Ref):
Low dose: 0.32 mmol/kg over 4 to 6 hours; use if serum phosphorus level 2.3 to 3 mg/dL (0.73 to 0.96 mmol/L).
Intermediate dose: 0.64 mmol/kg over 4 to 6 hours; use if serum phosphorus level 1.6 to 2.2 mg/dL (0.51 to 0.72 mmol/L).
High dose: 1 mmol/kg over 8 to 12 hours; use if serum phosphorus <1.5 mg/dL (<0.5 mmol/L).
Hypophosphatemia, chronic; prevention or maintenance treatment: Note: Dose should be individualized and may vary based on underlying conditions.
Infants, Children, and Adolescents: Oral: 2 to 3 mmol/kg/day in divided doses (Ref). Note: Parenteral solution for injection may be used enterally if oral dosage forms not appropriate (Ref).
Parenteral nutrition, maintenance phosphorus requirement (Ref):
Infants and Children ≤50 kg: IV: 0.5 to 2 mmol/kg/day of phosphorus as an additive to parenteral nutrition solution.
Children >50 kg and Adolescents: IV: 10 to 40 mmol/day of phosphorus as an additive to parenteral nutrition solution.
Dosage adjustment for concomitant therapy: Significant drug interactions exist, requiring dose/frequency adjustment or avoidance. Consult drug interactions database for more information.
There are no specific dosage adjustments provided in the manufacturer's labeling. However, because ionized inorganic phosphate is excreted by the kidneys, use with caution in patients with impaired kidney function:
Moderate impairment (eGFR ≥30 to <60 mL/minute/1.73 m2): Start at the lower end of dosage range.
Severe impairment (eGFR <30 mL/minute/1.73 m2), end-stage renal disease: Use is contraindicated.
There are no dosage adjustments provided in the manufacturer's labeling. Use with caution.
(For additional information see "Potassium phosphate: Drug information")
Hypophosphatemia, acute treatment:
Caution: The concomitant amount of potassium must be calculated into the total electrolyte content. For each 1 mmol of phosphate, ~1.5 mEq of potassium will be administered. Therefore, if ordering 30 mmol of potassium phosphate, the patient will receive ~45 mEq of potassium. With orders for IV phosphate, there is considerable confusion associated with the use of millimoles (mmol) versus milliequivalents (mEq) to express the phosphate requirement. The most reliable method of ordering IV phosphate is by millimoles, then specifying the potassium or sodium salt. Doses listed as mmol of phosphate.
Repletion of severe hypophosphatemia should be treated with IV phosphate as large doses of oral phosphate may cause diarrhea and intestinal absorption may be unreliable. Reserve intermittent IV infusion for severe depletion situations; may require continuous cardiac monitoring depending on potassium administration rate. Guidelines differ based on degree of illness, need/use of parenteral nutrition, and severity of hypophosphatemia. If potassium >4.0 mEq/L consider phosphate replacement strategy without potassium (eg, sodium phosphates). Patients with severe renal impairment were excluded from phosphate supplement trials. Note: 1 mmol phosphate = 31 mg phosphorus; 1 mg phosphorus = 0.032 mmol phosphate.
General replacement guidelines (Ref): Note: For initial or single doses in symptomatic patients; some patients may require lower or higher dose based on clinical presentation and renal function. Additional phosphate repletion can be given until the patient is asymptomatic or the phosphate level is >2 mg/dL. High variability exists in dosing/infusion rate recommendations; therapy guided by patient condition and specific institutional guidelines.
IV:
Low dose, serum phosphate level 2.3 to 2.7 mg/dL: Initial: 0.08 to 0.16 mmol/kg over 4 to 6 hours.
Intermediate dose, serum phosphate level 1.5 to 2.2 mg/dL: Initial: 0.16 to 0.32 mmol/kg over 4 to 6 hours.
High dose, serum phosphate level <1.5 mg/dL: Initial: 0.32 to 0.64 mmol/kg over 4 to 6 hours.
Obesity: May use adjusted body weight for patients weighing >130% of IBW (and BMI <40 kg/m2) by using (IBW + 0.25 [actual body weight − IBW]) (Ref).
Critically ill adult patients receiving concurrent enteral/parenteral nutrition (Ref): Note: Round doses to the nearest 7.5 mmol for ease of preparation. If administering with phosphate-containing parenteral nutrition, do not exceed 15 mmol/L within parenteral nutrition.
IV:
Low dose, serum phosphate level 2.3 to 3 mg/dL: Initial: 0.16 to 0.32 mmol/kg over 4 to 6 hours.
Intermediate dose, serum phosphate level 1.6 to 2.2 mg/dL: Initial: 0.32 to 0.64 mmol/kg over 4 to 6 hours.
High dose, serum phosphate <1.5 mg/dL: Initial: 0.64 to 1 mmol/kg over 8 to 12 hours.
Obesity: May use adjusted body weight for patients weighing >130% of IBW (and BMI <40 kg/m2) by using (IBW + 0.25 [actual body weight − IBW]) (Ref).
Urine acidification: Oral: 1 g 4 times daily.
Dosage adjustment for concomitant therapy: Significant drug interactions exist, requiring dose/frequency adjustment or avoidance. Consult drug interactions database for more information.
IV: There are no specific dosage adjustments provided in the manufacturer's labeling. Decrease initial dose by at least 50% if the patient has kidney impairment and is not receiving CRRT (Ref). In patients with severe kidney impairment, use only with extreme caution and close monitoring. In general, sodium phosphate is preferred in this population.
Oral: There are no specific dosage adjustments provided in the manufacturer's labeling. In patients with severe kidney impairment, use only with extreme caution and close monitoring.
There are no dosage adjustments provided in the manufacturer's labeling.
The following adverse drug reactions and incidences are derived from product labeling unless otherwise specified.
Frequency not defined:
Cardiovascular: Bradycardia, cardiac arrhythmia, chest pain, ECG changes, edema, heart block, hypotension, localized phlebitis (IV), prolonged QT interval on ECG
Endocrine & metabolic: Decreased serum magnesium, hyperkalemia, hyperphosphatemia, hypocalcemia
Gastrointestinal: Diarrhea, nausea, stomach pain, vomiting
Genitourinary: Decreased urine output
Nervous system: Confusion, lethargy, paralysis, paresthesia, seizures
Neuromuscular & skeletal: Asthenia, tetany (with large doses of phosphate)
Renal: Acute renal failure
Respiratory: Dyspnea
Hyperphosphatemia and hyperkalemia; severe renal impairment (eGFR <30 mL/minute/1.73 m2) and end-stage renal disease.
Injection: Hypercalcemia or significant hypocalcemia.
Oral: Infected phosphate stones.
Concerns related to adverse effects:
• Extravasation: Vesicant/irritant (may depend on concentration); ensure proper catheter or needle position prior to and during infusion. Avoid extravasation.
• Hyperkalemia: Severe hyperkalemia may occur and may cause life-threatening cardiac events, especially when administered in excessive doses, undiluted, or by rapid IV infusion. This risk is increased in patients with severe renal impairment and end-stage renal disease (ESRD), severe adrenal insufficiency or cardiac disease, and in patients who are receiving other drugs that increase the risk of hyperkalemia. Do not exceed the maximum daily amount of potassium or the recommended infusion rate; continuous ECG monitoring may be needed during infusion. Close monitoring of serum potassium concentrations is needed to avoid hyperkalemia; severe hyperkalemia may lead to muscle weakness/paralysis and cardiac conduction abnormalities (eg, heart block, ventricular arrhythmias, asystole).
• Hyperphosphatemia: May occur with administration, especially in patients with renal impairment or higher doses; may lead to hypocalcemia and associated symptoms (eg, neurological irritability with tetany), nephrocalcinosis with acute kidney injury and more rarely, cardiac irritability with arrhythmias.
• Hypomagnesemia: May cause a decrease in serum magnesium (and calcium) concentrations when administered to patients with hypercalcemia and diabetic ketoacidosis.
• Laxative effect: A mild laxative effect may occur with oral use within the first few days of therapy; if the laxative effect persists to a self-limiting degree, consider reducing the dose or discontinue use until diarrhea improves.
Disease-related concerns:
• Acid/base disorders: Use with caution in patients with acid/base alterations; changes in serum potassium concentrations can occur during acid/base correction, monitor closely.
• Adrenal insufficiency: Use with caution in patients with severe adrenal insufficiency (eg, Addison disease); adrenal insufficiency requires close monitoring of serum potassium and phosphorus concentrations to avoid hyperkalemia and/or hyperphosphatemia.
• Cardiovascular disease: Use with caution in patients with cardiovascular disease (eg, heart failure, cardiac arrhythmias); patients may be more susceptible to life-threatening cardiac effects associated with hyper/hypokalemia.
• Dehydration: Use with caution in patients with acute dehydration.
• Myotonia congenita: Use with caution in patients with myotonia congenita.
• Pancreatitis: Use with caution in patients with acute pancreatitis.
• Parathyroid disease: Use with caution in patients with hypoparathyroidism.
• Renal calculi: Patients with renal calculi may pass preformed stones when phosphate therapy is initiated.
• Renal impairment: Use with caution in patients with renal impairment; renal impairment requires close monitoring of serum potassium and phosphorus concentrations to avoid hyperkalemia and/or hyperphosphatemia. In general, use is contraindicated in patients with severe renal impairment and ESRD; if used in this population, use with caution and at lower doses and more frequent monitoring. In patients with moderate renal insufficiency (eGFR ≥30 to <60 mL/minute/1.73 m2), start at lower end of dosing range and monitor potassium and other electrolytes more frequently.
• Rickets: Use with caution in patients with rickets; may increase the risk of extraskeletal calcification.
• Tissue breakdown: Use with caution in patients with extensive tissue breakdown (eg, severe burns).
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). Exposure to aluminum from injection is not more than 4.9 mcg/kg/day for parenteral nutrition when adults ≥45 kg are administered the recommended maximum dose (45 mmol/day) or pediatric patients ≥12 years of age and ≥40 kg are administered the recommended maximum dose (40 mmol/day) according to the CMP Pharma product labeling. Aluminum content may vary by manufacturer. In 2023, the FDA issued a warning against using Hospira potassium phosphate product in pediatric patients due to the high aluminum content (FDA 2023).
• Oral administration: Tablets should be dissolved completely in water prior to administration to avoid GI injury due to administration of a concentrated potassium salt preparation.
• Parenteral administration: Use extreme caution when administering potassium phosphate parenterally; evaluate patient's renal function, cardiac and fluid status, and any factors contributing to altered potassium concentrations (eg, acid-base disorders) prior to therapy. Parenteral potassium must be diluted and administered in IV fluids or used as an admixture in parenteral nutrition; not for direct IV infusion which may cause vein irritation, damage, and/or thrombosis. Avoid undiluted, bolus or rapid IV administration; single doses of IV phosphate ≥50 mmol (adults) and/or rapid infusion rates (over 1 to 3 hours) have resulted in death, cardiac arrest, cardiac arrhythmia (including QT prolongation), hyperkalemia, hyperphosphatemia, hypotension, and seizures. Administration of undiluted or insufficiently diluted potassium phosphate (ie, IV push) has resulted in cardiac arrest, cardiac arrhythmias, hypotension, and death.
• Precipitates: Periodically inspect solution, infusion set, and catheter for precipitates. Pulmonary vascular precipitates causing pulmonary vascular emboli and pulmonary distress have been reported in admixed products containing calcium and phosphates, or parenteral nutrition. If signs of pulmonary distress occur, stop the infusion.
Excipient information presented when available (limited, particularly for generics); consult specific product labeling.
Injection, solution:
Generic: Potassium 4.4 mEq and phosphorus 3 mmol per mL (5 mL) [equivalent to potassium 170 mg and elemental phosphorus 93 mg per mL]; potassium 4.7 mEq and phosphorus 3 mmol per mL (15 mL) [equivalent to potassium 184 mg and phosphorous 93 mg per mL]
Tablet, Oral:
K-Phos: 500 mg [scored]
Phospho-Trin K500: 500 mg
Yes: Injection
Solution (Potassium Phosphates Intravenous)
15 mmole/5ml (per mL): $5.52 - $5.76
150 mmole/50ml (per mL): $2.81 - $2.85
Solution (Potassium Phosphates(66 mEq K) Intravenous)
45 mmole/15ml (per mL): $1.18 - $3.84
Solution (Potassium Phosphates(71 mEq K) Intravenous)
45 mmole/15ml (per mL): $2.99
Tablets (K-Phos Oral)
500 mg (per each): $0.64
Tablets (Phospho-Trin K500 Oral)
500 mg (per each): $0.77
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.
Cow's milk is a good source of phosphate with 1 mg elemental (0.032 mmol) elemental phosphate per mL.
IV: Note: In general, the dose, concentration of infusion, and rate of administration may be dependent on patient condition and specific institution policy. Must consider administration precautions for both phosphate and potassium when prescribing.
Intermittent IV infusion: Must be diluted in appropriate IV solution and volume prior to administration and infused slowly to avoid potassium and/or phosphate toxicity. Infusion of dose over 4 to 6 hours for mild/moderate hypophosphatemia or 8 to 12 hours for severe hypophosphatemia has been recommended (Ref). Faster administration rates (eg, 30 mmol over 2 hours, 45 mmol over 3 hours) have been reported in adults with moderate to severe hypophosphatemia without adverse effects (Ref); major adverse effects have been reported in adults administered doses ≥50 mmol infused over ≤3 hours (Ref). Some manufacturers recommend the following maximum infusion rates for pediatric patients ≥12 years:
Central line: 15 mmol phosphorus/hour (~23 mEq potassium/hour). Note: Maximum concentration and potassium content varies slightly by product; see product-specific labeling for details.
Peripheral line: ~6.5 mmol phosphorus/hour (10 mEq potassium/hour). Note: Maximum concentration and potassium content varies slightly by product; see product-specific labeling for details.
Verify infusion time does not exceed acceptable potassium infusion rates: Usual pediatric infusion rates for potassium (including all sources): 0.3 to 0.5 mEq/kg/hour; maximum rate: 1 mEq/kg/hour up to 40 mEq/hour; ECG monitoring is recommended for potassium infusions >0.5 mEq/kg/hour in patients <20 kg or >10 mEq/hour in patients ≥20 kg. Do not infuse with calcium-containing IV fluids.
Parenteral nutrition solution: 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, the more soluble the calcium and phosphate. Individual commercially available amino acid solutions vary significantly with respect to pH lowering potential and subsequent calcium phosphate compatibility; consult product specific labeling for additional information.
Vesicant/irritant (may depend on concentration); ensure proper needle or catheter placement prior to and during IV infusion. Avoid extravasation. If 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 (Ref); elevate extremity.
Oral: Parenteral solution for injection may be used enterally (Ref).
IV: Injection must be diluted in appropriate IV solution and volume prior to administration; do not administer IV push. In general, the dose, concentration of infusion, and rate of administration may be dependent on patient condition/indication and specific institution policy. Must consider administration precautions for phosphate and potassium when prescribing.
For patients with severe symptomatic hypophosphatemia (ie, <1.5 mg/dL), may administer at rates up to 15 mmol phosphate/hour (this rate will deliver potassium at 22.5 mEq/hour) (Ref). The maximum rate of administration for peripheral infusion is ~6.4 mmol phosphate per hour (potassium 10 mEq/hour). The maximum rate for central administration is ~15 mmol phosphate per hour (potassium 23.5 mEq/hour). In patients with renal dysfunction and/or less severe hypophosphatemia, slower administration rates (eg, over 4 to 6 hours) or oral repletion is recommended. Potassium infusion rates >10 mEq/hour should be administered via central line (minimizes burning and phlebitis). ECG monitoring is recommended for potassium infusions >10 mEq/hour.
Vesicant/irritant (may depend on concentration); ensure proper needle or catheter placement prior to and during IV infusion. Avoid extravasation.
Extravasation management: 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 mL (15 units/mL) as five separate 0.2 mL injections (using a tuberculin syringe) around the site of extravasation; if IV catheter remains in place, administer IV through the infiltrated catheter; may repeat in 30 to 60 minutes if no resolution (Ref).
Oral: Administer at mealtime and at bedtime. Dissolve tablets in 6 to 8 oz of water prior to administration to avoid GI injury. For best results, soak tablets in water for at least 2 to 5 minutes and stir. If any tablet particles remain undissolved, crush and stir vigorously to speed dissolution.
Injection:
Vials containing potassium 4.4 mEq/mL: Store intact vials at 20°C to 25°C (68°F to 77°F). Use the pharmacy bulk package vial as soon as the sterile transfer set has been inserted or may store at 20°C to 25°C (68°F to 77°F) for a maximum of 4 hours after the container closure has been penetrated. Diluted solutions for infusion are stable for a maximum of 4 hours at 20°C to 25°C (68°F to 77°F) or 14 days at 2°C to 8°C (36°F to 46°F).
Vials containing potassium 4.7 mEq/mL: Store intact vials at 2°C to 8°C (36°F to 46°F). Do not freeze. Diluted solutions for infusion are stable for 48 hours at 2°C to 8°C (36°F to 46°F) or at 20°C to 25°C (68°F to 77°F).
Oral: Store at 20°C to 25°C (68°F to 77°F); excursions permitted between 15°C to 30°C (59°F to 86°F). Dispense in a tight, light-resistant container.
Parenteral: Treatment and prevention of hypophosphatemia and source of phosphate in large volume IV fluids, including parenteral nutrition (FDA approved in all ages; approved ages may vary by product; consult product-specific labeling for details). Note: FDA recommends against use of Hospira potassium phosphate product in pediatric patients due to the high aluminum content (FDA 2023).
Oral: To acidify the urine to lower urinary calcium concentrations; to reduce odor and rash caused by ammonia in urine; to increase the antibacterial activity of methenamine (FDA approved in adults).
Neutra-Phos-K [DSC] may be confused with K-Phos Neutral
The Institute for Safe Medication Practices (ISMP) includes this medication (IV formulation) among its list of drugs which have a heightened risk of causing significant patient harm when used in error.
Per JCAHO recommendations, concentrated electrolyte solutions should not be available in patient care areas.
Consider special storage requirements for intravenous potassium salts; IV potassium salts have been administered IVP in error, leading to fatal outcomes.
Safe Prescribing: Because inorganic phosphate exists as monobasic and dibasic anions, with the mixture of valences dependent on pH, ordering by mEq amounts is unreliable and may lead to large dosing errors. In addition, IV phosphate is available in the sodium and potassium salt; therefore, the content of these cations must be considered when ordering phosphate. The most reliable method of ordering IV phosphate is by millimoles, then specifying the potassium or sodium salt. For example, an order for 15 mmol of phosphate as potassium phosphate in one liter of normal saline.
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.
Aliskiren: Potassium Salts may enhance the hyperkalemic effect of Aliskiren. Risk C: Monitor therapy
Alpha-/Beta-Agonists (Indirect-Acting): Urinary Acidifying Agents may decrease the serum concentration of Alpha-/Beta-Agonists (Indirect-Acting). Risk C: Monitor therapy
Amantadine: Urinary Acidifying Agents may decrease the serum concentration of Amantadine. Risk C: Monitor therapy
AMILoride: Potassium Salts may enhance the hyperkalemic effect of AMILoride. Management: Amiloride and potassium supplements should not be used except in severe or refractory cases of hypokalemia. If coadministered, monitor serum potassium closely as rapid increases in potassium are possible. Risk D: Consider therapy modification
Amphetamines: Urinary Acidifying Agents may decrease the serum concentration of Amphetamines. Risk C: Monitor therapy
Angiotensin II Receptor Blockers: Potassium Salts may enhance the hyperkalemic effect of Angiotensin II Receptor Blockers. Risk C: Monitor therapy
Angiotensin-Converting Enzyme Inhibitors: Potassium Salts may enhance the hyperkalemic effect of Angiotensin-Converting Enzyme Inhibitors. Risk C: Monitor therapy
Antacids: May decrease the serum concentration of Potassium Phosphate. Management: Consider separating administration of antacids and oral potassium phosphate by at least 2 hours to decrease risk of a significant interaction. Risk D: Consider therapy modification
Burosumab: Phosphate Supplements may enhance the adverse/toxic effect of Burosumab. Risk X: Avoid combination
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
ChlorproPAMIDE: Urinary Acidifying Agents may increase the serum concentration of ChlorproPAMIDE. Risk C: Monitor therapy
Drospirenone-Containing Products: May enhance the hyperkalemic effect of Potassium Salts. Risk C: Monitor therapy
Eplerenone: May enhance the hyperkalemic effect of Potassium Salts. Management: This combination is contraindicated in patients receiving eplerenone for treatment of hypertension. Potassium supplements may be needed to treat/prevent hypokalemia in select patients with heart failure receiving eplerenone and high dose loop diuretics. Risk D: Consider therapy modification
Erdafitinib: Serum Phosphate Level-Altering Agents may diminish the therapeutic effect of Erdafitinib. Management: Avoid coadministration of serum phosphate level-altering agents with erdafitinib before initial dose increase period based on serum phosphate levels (Days 14 to 21). Risk D: Consider therapy modification
Finerenone: Potassium Salts may enhance the hyperkalemic effect of Finerenone. Risk C: Monitor therapy
Heparins (Low Molecular Weight): May enhance the hyperkalemic effect of Potassium Salts. Risk C: Monitor therapy
Iron Preparations: May decrease the absorption of Phosphate Supplements. Management: Administer oral phosphate supplements as far apart from the administration of an oral iron preparation as possible to minimize the significance of this interaction. Risk D: Consider therapy modification
Magnesium Salts: May decrease the serum concentration of Phosphate Supplements. Management: Administer oral phosphate supplements as far apart from the administration of an oral magnesium salt as possible to minimize the significance of this interaction. Risk D: Consider therapy modification
Mecamylamine: Urinary Acidifying Agents may decrease the serum concentration of Mecamylamine. Risk C: Monitor therapy
Multivitamins/Minerals (with ADEK, Folate, Iron): May decrease the serum concentration of Phosphate Supplements. Management: Administer oral phosphate supplements as far apart from the administration of an iron-containing oral multivitamin as possible to minimize the significance of this interaction. Risk D: Consider therapy modification
Nicorandil: May enhance the hyperkalemic effect of Potassium Salts. Risk C: Monitor therapy
Nonsteroidal Anti-Inflammatory Agents: May enhance the hyperkalemic effect of Potassium Salts. Risk C: Monitor therapy
Salicylates: Potassium Phosphate may increase the serum concentration of Salicylates. Risk C: Monitor therapy
Spironolactone: Potassium Salts may enhance the hyperkalemic effect of Spironolactone. Risk X: Avoid combination
Sucralfate: May decrease the absorption of Phosphate Supplements. Management: This applies only to oral phosphate administration. Administering oral phosphate supplements at least 2 hours before sucralfate may reduce the significance of the interaction. Risk D: Consider therapy modification
Triamterene: Potassium Salts may enhance the hyperkalemic effect of Triamterene. Risk X: Avoid combination
Uva Ursi: Urinary Acidifying Agents may diminish the therapeutic effect of Uva Ursi. Management: Consider avoiding use of uva ursi with agents that acidify the urine, as this may impair uva ursi efficacy. Risk D: Consider therapy modification
Avoid administering with oxalate (berries, nuts, chocolate, beans, celery, tomato) or phytate-containing foods (bran, whole wheat).
Phosphorous:
Dietary adequate intake (AI) (IOM 1997):
1 to 6 months: 3.2 mmol/day (100 mg/day).
7 to 12 months: 8.9 mmol/day (275 mg/day).
Dietary recommended daily allowance (RDA) (IOM 1997):
1 to 3 years: 14.8 mmol/day (460 mg/day).
4 to 8 years: 16.1 mmol/day (500 mg/day).
9 to 18 years: 40.3 mmol/day (1,250 mg/day).
Animal reproduction studies have not been conducted. Phosphorus requirements are the same in pregnant and nonpregnant women (IOM 1997). Although this product is not used for potassium supplementation, adverse events have not been observed following use of potassium supplements in healthy women with normal pregnancies. Use caution in pregnant women with other medical conditions (eg, preeclampsia; may be more likely to develop hyperkalemia) (IOM 2004).
Serum potassium, calcium, magnesium, and phosphorus concentrations; renal function; in pediatric patients after IV phosphate repletion, repeat serum phosphorus and potassium concentrations should be checked 1 to 2 hours later (ASPEN [Corkins 2015]); cardiac monitoring (if intermittent infusion or potassium infusion rates >0.5 mEq/kg/hour in pediatric patients <20 kg or >10 mEq/hour in patients ≥20 kg).
Phosphorous: Note: There is a diurnal variation with the nadir at 1100 hours, plateau at 1600 hours, and peak in the early evening (Gaasbeek 2005); 1 mmol/L phosphate = 3.1 mg/dL phosphorus.
Neonates 0 to 5 days: 4.8 to 8.2 mg/dL (Kliegman 2020).
Children 1 to <4 years: 3.8 to 6.5 mg/dL (Kliegman 2020).
Children 4 to <6 years: 3.7 to 6 mg/dL (Adeli 2015; Kliegman 2020).
Children 6 to <12 years: 3.7 to 5.7 mg/dL (Adeli 2015; Kliegman 2020).
Children ≥12 years and Adolescents <16 years: 2.9 to 5.9 mg/dL (Adeli 2015; Kliegman 2020).
Adolescents 16 to 18 years: 2.7 to 4.7 mg/dL (Adeli 2015; Kliegman 2020).
Potassium, serum:
Neonates <7 days: 3.2 to 5.5 mmol/L (Greeley 1993; Kliegman 2020).
Neonates ≥7 to 30 days: 3.4 to 6 mmol/L (Greeley 1993; Kliegman 2020).
Infants <6 months: 3.5 to 5.6 mmol/L (Greeley 1993; Kliegman 2020).
Infants ≥6 months: 3.5 to 6.1 mmol/L (Greeley 1993; Kliegman 2020).
Children <6 years: 3.3 to 4.6 mmol/L (Adeli 2015; Greeley 1993; Kliegman 2020).
Children ≥6 years and Adolescents: 3.3 to 4.9 mmol/L (Adeli 2015; Greeley 1993; Kliegman 2020).
Phosphorus in the form of organic and inorganic phosphate has a variety of important biochemical functions in all organs and tissues, including critical roles in nucleic acid structure, energy storage and transfer, cell signaling, cell membrane composition and structure, acid-base balance, mineral homeostasis, and bone mineralization.
Potassium is the major cation of intracellular fluid and is essential for the conduction of nerve impulses in heart, brain, and skeletal muscle; contraction of cardiac, skeletal and smooth muscles; maintenance of normal renal function, acid-base balance, carbohydrate metabolism, and gastric secretion.
Absorption: Oral: Well absorbed from upper GI tract.
Distribution: Enters cells via active transport from extracellular fluid; ~85% of serum phosphates is free and ultra-filterable.
Protein binding: 15%.
Excretion: Primarily urine (>80% to 90% of dose reabsorbed by the kidney); skin and feces (small amounts).
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