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Sodium citrate, potassium citrate, and citric acid (oral solution): Drug information

Sodium citrate, potassium citrate, and citric acid (oral solution): Drug information
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Brand Names: US
  • Cytra-3;
  • Tricitrates SF;
  • Virtrate-3 [DSC]
Pharmacologic Category
  • Alkalinizing Agent
Dosing: Adult
Alkalinizing agent/bicarbonate precursor/potassium supplement

Alkalinizing agent/bicarbonate precursor/potassium supplement: Oral: 15 to 30 mL diluted in water after meals and at bedtime.

Dosing: Older Adult

Refer to adult dosing.

Dosing: Pediatric

(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, distal

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 (Ref).

Renal tubular acidosis, proximal

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 (Ref); 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 (Ref).

Systemic alkalinization; chronic

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) (Ref).

Adverse Reactions

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

Contraindications

Severe renal impairment with oliguria or azotemia; untreated Addison’s disease; severe myocardial damage.

Warnings/Precautions

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).

Warnings: Additional Pediatric Considerations

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).

Dosage Forms Considerations

Each mL contains 1 mEq potassium ion and 1 mEq sodium ion, and is equivalent to 2 mEq bicarbonate (HCO3).

Dosage Forms: US

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)

Generic Equivalent Available: US

Yes

Pricing: US

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.

Administration: Adult

Administer after meals. Dilute with water prior to administration. Chilling solution prior to dosing helps to enhance palatability. May follow dose with additional fluids.

Administration: Pediatric

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.

Use: Labeled Indications

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

Medication Safety Issues
Sound-alike/look-alike issues:

Polycitra may be confused with Bicitra

Metabolism/Transport Effects

Refer to individual components.

Drug Interactions

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 drug interactions program by clicking on the “Launch drug interactions program” link above.

Agents with Clinically Relevant Anticholinergic Effects: May increase ulcerogenic effects 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

Aliskiren: Potassium Salts may increase hyperkalemic effects of Aliskiren. Risk C: Monitor

Aluminum Hydroxide: Citric Acid Derivatives may increase absorption of Aluminum Hydroxide. Risk C: Monitor

Amantadine: Alkalinizing Agents may increase serum concentration of Amantadine. Risk C: Monitor

AMILoride: Potassium Salts may increase hyperkalemic effects 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 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 increase hyperkalemic effects of Angiotensin II Receptor Blockers. Risk C: Monitor

Angiotensin-Converting Enzyme Inhibitors: Potassium Salts may increase hyperkalemic effects of Angiotensin-Converting Enzyme Inhibitors. Risk C: Monitor

CycloSPORINE (Systemic): May increase hyperkalemic effects of Potassium Salts. Risk C: Monitor

Digitoxin: Potassium Salts may increase adverse/toxic effects of Digitoxin. Potassium Salts may decrease therapeutic effects of Digitoxin. Risk C: Monitor

Drospirenone-Containing Products: May increase hyperkalemic effects of Potassium Salts. Risk C: Monitor

Eplerenone: May increase hyperkalemic effects 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 increase hyperkalemic effects of Finerenone. Risk C: Monitor

Flecainide: Alkalinizing Agents may decrease excretion of Flecainide. Risk C: Monitor

Heparin: May increase hyperkalemic effects of Potassium Salts. Risk C: Monitor

Heparins (Low Molecular Weight): May increase hyperkalemic effects of Potassium Salts. Risk C: Monitor

Mecamylamine: Alkalinizing Agents may increase serum concentration of Mecamylamine. Risk C: Monitor

Memantine: Alkalinizing Agents may increase serum concentration of Memantine. Risk C: Monitor

Nicorandil: May increase hyperkalemic effects of Potassium Salts. Risk C: Monitor

Nonsteroidal Anti-Inflammatory Agents: May increase hyperkalemic effects of Potassium Salts. Risk C: Monitor

QuiNIDine: Alkalinizing Agents may increase serum concentration of QuiNIDine. Risk C: Monitor

QuiNINE: Alkalinizing Agents may increase serum concentration of QuiNINE. Risk C: Monitor

Spironolactone: Potassium Salts may increase hyperkalemic effects of Spironolactone. Risk X: Avoid

Triamterene: Potassium Salts may increase hyperkalemic effects of Triamterene. Risk X: Avoid

Dietary Considerations

Should be taken after meals to avoid GI upset or laxative effect.

Monitoring Parameters

Serum potassium, sodium, and bicarbonate; urinary pH

Reference Range

Note: Reference ranges may vary depending on the laboratory

Urinary pH: 4.6-8.0

Pharmacokinetics (Adult Data Unless Noted)

Metabolism: ≥95% via hepatic oxidation to bicarbonate

Excretion: Urine (<5% as unchanged drug)

Brand Names: International
International Brand Names by Country
For country code abbreviations (show table)

  • (QA) Qatar: Tricitrates | Uralyt-U
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  8. Potassium Citrate, Sodium Citrate, and Citric Acid [prescribing information]. Nashville, TN: Westminster Pharmaceuticals LLC; April 2021.
  9. Rodríguez Soriano J. Renal tubular acidosis: the clinical entity. J Am Soc Nephrol. 2002;13(8):2160-2170. [PubMed 12138150]
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  12. Tricitrates (potassium citrate monohydrate, sodium citrate dihydrate, and citric acid monohydrate) oral solution, USP [prescribing information]. Congers, NY: Chartwell Rx LLC; December 2022.
  13. Tricitrates SF (potassium citrate, sodium citrate dihydrate, and citric acid monohydrate) [prescribing information]. Greenville, SC: Pharmaceutical Associates Inc; August 2022.
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