Version May 2024
Alkalinizing agent/bicarbonate precursor/potassium supplement: Oral: 15 to 30 mL diluted in water after meals and at bedtime.
Refer to adult dosing.
(For additional information see "Sodium citrate, potassium citrate, and citric acid (oral solution): Pediatric drug information")
Note: Consider the contribution of sodium and potassium when determining the appropriate bicarbonate replacement: 1 mL of oral solution contains 2 mEq of bicarbonate, 1 mEq of sodium, and 1 mEq of potassium. Individualize dose as determined by disease and patient-specific targets.
Renal tubular acidosis (RTA), distal (Type 1): Limited data available: Note: Dose requirements may vary with age. Infants, Children, and Adolescents: Oral: Usual dose: 2 to 4 mEq bicarbonate/kg/day (1 to 2 mL/kg/day) in divided doses; reported range: 1 to 7 mEq bicarbonate/kg/day; adjust dose to maintain target serum CO2 (Chan 2001; Kliegman 2016; Rodríguez Soriano 2002; Santos 1986).
Renal tubular acidosis (RTA), proximal (Type 2): Limited data available: Note: Dose requirements may vary with age; for Type 2 RTA, bicarbonate doses are higher than those required for other types of RTA. Infants, Children, and Adolescents: Oral: Usual range: 10 to 20 mEq bicarbonate/kg/day (5 to 10 mL/kg/day) in divided doses (Chan 2001; Kliegman 2016; Rodríguez Soriano 2002); Note: May not be appropriate as monotherapy in some cases due to high therapeutic alkali requirement and corresponding potassium load; could be used in combination with sodium citrate formulations to meet alkali needs (Rodríguez Soriano 2002).
Systemic alkalinization; chronic:
Volume-based dosing: Children and Adolescents: Oral: 5 to 15 mL (10 to 30 mEq bicarbonate) per dose after meals and at bedtime.
Weight-based dosing (mEq bicarbonate/kg): Limited data available: Infants, Children, and Adolescents: Oral: 2 to 3 mEq bicarbonate/kg/day (1 to 1.5 mL/kg/day) in 3 to 4 divided doses; adjust dose to targeted serum bicarbonate levels; typical adult doses do not exceed 60 mEq/dose (30 mL/dose) (Gal 2007).
The following adverse drug reactions and incidences are derived from product labeling unless otherwise specified. Frequency not defined.
Cardiovascular: Cardiac abnormalities
Endocrine & metabolic: Metabolic alkalosis, calcium levels, hyperkalemia, hypernatremia
Gastrointestinal: Diarrhea
Neuromuscular & skeletal: Tetany
Severe renal impairment with oliguria or azotemia; untreated Addison’s disease; severe myocardial damage.
Disease-related concerns:
• Cardiovascular disease: Use with caution in patients with heart failure or hypertension; contains sodium.
• Edema: Use with caution in patients with peripheral or pulmonary edema; contains sodium.
• Hepatic impairment: Citrate is converted to bicarbonate in the liver; this conversion may be blocked in patients in hepatic failure.
• Renal impairment: Use with caution in patients with renal impairment; contains sodium. Contraindicated in patients with severe impairment.
• Severely ill: Use with caution in patients who are severely ill; conversion to bicarbonate may be impaired.
• Shock: Use with caution in patients who are in shock; conversion to bicarbonate may be impaired.
Concurrent drug therapy issues:
• Digitalis: Use with caution in digitalized patients; may be more susceptible to potentially life-threatening cardiac effects with rapid changes in serum potassium concentrations.
• Potassium-altering therapies: Use with caution in patients receiving concomitant medications or therapies that increase potassium (eg, ACEI, potassium-sparing diuretics, potassium containing salt substitutes).
Dosage form specific issues:
• Benzyl alcohol and derivatives: Some dosage forms may contain sodium benzoate/benzoic acid; benzoic acid (benzoate) is a metabolite of benzyl alcohol; large amounts of benzyl alcohol (≥99 mg/kg/day) have been associated with a potentially fatal toxicity (“gasping syndrome”) in neonates; the “gasping syndrome” consists of metabolic acidosis, respiratory distress, gasping respirations, CNS dysfunction (including convulsions, intracranial hemorrhage), hypotension, and cardiovascular collapse (AAP ["Inactive" 1997]; CDC, 1982); some data suggests that benzoate displaces bilirubin from protein binding sites (Ahlfors, 2001); avoid or use dosage forms containing benzyl alcohol derivative with caution in neonates. See manufacturer’s labeling.
• Propylene glycol: Some dosage forms may contain propylene glycol; large amounts are potentially toxic and have been associated hyperosmolality, lactic acidosis, seizures, and respiratory depression; use caution (AAP ["Inactive" 1997]; Zar, 2007).
Some dosage forms may contain propylene glycol; in neonates large amounts of propylene glycol delivered orally, intravenously (eg, >3,000 mg/day), or topically have been associated with potentially fatal toxicities which can include metabolic acidosis, seizures, renal failure, and CNS depression; toxicities have also been reported in children and adults including hyperosmolality, lactic acidosis, seizures and respiratory depression; use caution (AAP 1997; Shehab 2009).
Each mL contains 1 mEq potassium ion and 1 mEq sodium ion, and is equivalent to 2 mEq bicarbonate (HCO3).
Excipient information presented when available (limited, particularly for generics); consult specific product labeling. [DSC] = Discontinued product
Solution, Oral:
Cytra-3: Citric acid 334 mg, sodium citrate 500 mg, and potassium citrate 550 mg per 5 mL (473 mL) [sugar free; contains fd&c yellow #6, polyethylene glycol, propylene glycol, sodium benzoate, sodium saccharin; raspberry flavor]
Tricitrates SF: Citric acid 334 mg, sodium citrate 500 mg, and potassium citrate 550 mg per 5 mL (473 mL) [sugar free; contains fd&c yellow #6, polyethylene glycol, proplyene glycol, sodium benzoate, sorbitol; raspberry flavor]
Virtrate-3: Citric acid 334 mg, sodium citrate 500 mg, and potassium citrate 550 mg per 5 mL (473 mL [DSC]) [sugar free; contains fd&c yellow #6 (sunset yellow), polyethylene glycol, propylene glycol, saccharin sodium, sodium benzoate; raspberry flavor]
Generic: Citric acid 334 mg, sodium citrate 500 mg, and potassium citrate 550 mg per 5 mL (473 mL)
Yes
Solution (Pot & Sod Cit-Cit Ac Oral)
550-500-334 mg/5 mL (per mL): $0.15
Syrup (Cytra-3 Oral)
550-500-334 mg/5 mL (per mL): $0.15
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.
Administer after meals. Dilute with water prior to administration. Chilling solution prior to dosing helps to enhance palatability. May follow dose with additional fluids.
Oral: Dose should be diluted in water; may follow dose with additional water if necessary. Administer after meals and at bedtime to prevent osmotic saline laxative effect; shake well before use. Chilling solution prior to dosing helps to enhance palatability.
Conditions where long-term maintenance of an alkaline urine is desirable as in control and dissolution of uric acid and cystine calculi of the urinary tract
Polycitra may be confused with Bicitra
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): Alkalinizing Agents may increase the serum concentration of Alpha-/Beta-Agonists (Indirect-Acting). Risk C: Monitor therapy
Aluminum Hydroxide: Citric Acid Derivatives may increase the absorption of Aluminum Hydroxide. Risk C: Monitor therapy
Amantadine: Alkalinizing Agents may increase 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: Alkalinizing Agents may decrease the excretion of Amphetamines. Management: Consider alternatives to using amphetamines and alkalinizing agents in combination. If these agents must be used together, patients should be monitored closely for excessive amphetamine effects. Risk D: Consider therapy modification
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
Anticholinergic Agents: May enhance the ulcerogenic effect of Potassium Citrate. Management: Patients on drugs with substantial anticholinergic effects should avoid using any solid oral dosage form of potassium citrate. Risk X: Avoid combination
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
Finerenone: Potassium Salts may enhance the hyperkalemic effect of Finerenone. Risk C: Monitor therapy
Flecainide: Alkalinizing Agents may decrease the excretion of Flecainide. Risk C: Monitor therapy
Heparins (Low Molecular Weight): May enhance the hyperkalemic effect of Potassium Salts. Risk C: Monitor therapy
Mecamylamine: Alkalinizing Agents may increase the serum concentration of Mecamylamine. Risk C: Monitor therapy
Memantine: Alkalinizing Agents may increase the serum concentration of Memantine. Risk C: Monitor therapy
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
QuiNINE: Alkalinizing Agents may increase the serum concentration of QuiNINE. Risk C: Monitor therapy
Spironolactone: Potassium Salts may enhance the hyperkalemic effect of Spironolactone. Risk X: Avoid combination
Triamterene: Potassium Salts may enhance the hyperkalemic effect of Triamterene. Risk X: Avoid combination
Should be taken after meals to avoid GI upset or laxative effect.
Serum potassium, sodium, and bicarbonate; urinary pH
Note: Reference ranges may vary depending on the laboratory
Urinary pH: 4.6-8.0
Metabolism: ≥95% via hepatic oxidation to bicarbonate
Excretion: Urine (<5% as unchanged drug)
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