Drugs List

Therapeutic Indications

Uses

Acute hypocalcaemia
Neonatal hypocalcaemia
Tetany - hypocalcaemic
Cardiac resuscitation
Neonatal tetany
Acute colic of lead poisoning
Acute fluoride poisoning (adjunct)
Hypocalcaemia prevention in exchange transfusions
Hyperkalaemia (prevention of arrhythmias)

Administration

By intravenous injection or by continuous intravenous infusion.

Intravenous injection
Administration rate should not exceed 2ml (0.45mmol of calcium) per minute. For neonates and children see Dosage section.
Monitor for extravasation as irritation and/or possible soft tissue calcification may occur. Where appropriate use the oral route as soon as possible due to the risk of extravasation.

Continuous infusion
Dosage and rate of infusion is variable and depends upon the size of the individual, the indication and the clinical condition.
For children dilute to at least 45micromol/ml with glucose 5% or sodium chloride 0.9%. Maximum administration rate 45micromol/kg/hour (or in neonates maximum 22micromol/kg/hour). May be given more concentrated via a central venous catheter.

Use only if the solution is clear.

Reconstitution

Further dilution into a larger volume should be carried out for all continuous intravenous infusions (see Compatibilities).

Compatibilities

Calcium gluconate injection can be diluted with glucose injection 5% or sodium chloride injection 0.9%.

Incompatibilities

Calcium salts can form complexes with many drugs which may result in a precipitate. Calcium salts are incompatible with oxidising agents, citrates, soluble carbonates, bicarbonates, phosphates, tartrates and sulfates. Physical incompatibility has also been reported with amphotericin, cephalothin sodium, cephazolin sodium, cephamandole nafate, novobiocin sodium, dobutamine hydrochloride, prochlorperazine, and tetracyclines.

In patients of any age ceftriaxone must not be mixed or administered simultaneously with any calcium-containing IV solutions, even via different infusion lines or at different infusion sites.

Care should be taken to avoid admixtures of calcium gluconate and incompatible drugs in giving sets, or in the circulation after separate administration.

Contraindications

Hypercalcaemia e.g. in hyperparathyroidism, hypervitaminosis D or neoplastic disease with decalcification of bone.

Severe hypercalciuria.

Concurrent cardiac glycosides - digitalis intoxication may be precipitated.

Calcium gluconate should not be used for long term or repeated treatment in children under 18 years and those with impaired renal function as aluminium oxide can be leached from the glass ampoules.

Calcium gluconate should not be used in the preparation of total parenteral nutrition especially in those with impaired renal function and in children under 18 to limit the expose to aluminium.

Precautions and Warnings

Use with caution in patients with renal impairment, nephrolithiasis, history of nephrolithiasis and nephrocalcinosis. Manufacturer contraindicates the use of calcium gluconate 10% injection in patients with severe renal impairment. See Dosage - Renal Impairment .

Use with caution in patients with cardiac disorder.

Use with caution in patients with sarcoidosis.

Elderly

Children under 18 years - see Contraindications.

Pregnancy (see Pregnancy section)

Breastfeeding (see Lactation section)

Monitor plasma calcium levels and calcium excretion, especially in children, in chronic renal failure or where there is evidence of calculi formation within urinary tract.

If plasma calcium exceeds 2.75mmol per litre or if 24 hour urinary calcium excretion exceeds 5mg/kg, treatment should be discontinued immediately as cardiac arrhythmias may occur at these levels.

Calcium salts are irritant. Administer carefully and monitor injection site due to risk of extravasation.

Pregnancy and Lactation

Pregnancy

Use only if considered essential by a physician. Caution and close monitoring is required.

The use of all medication in pregnancy should be avoided whenever possible; particularly in the first trimester. Non-drug treatments should also be considered. When essential, a medication with the best safety record over time should be chosen, employing the lowest effective dose for the shortest possible time. Polypharmacy should be avoided. Teratogens taken in the pre-embryonic period, often quoted as lasting until 14-17 days post-conception, are believed to have an all-or-nothing effect. Where drugs have a short half-life, and when the date of conception is certain, this may allow women to be reassured where drug exposure has occurred within this time frame. Further advice may be available from the UK National Teratology Information Service (NTIS) and through ToxBase, available via password on the internet ( www.toxbase.org ) or if this is unavailable at the backup site ( www.toxbasebackup.org ).

Lactation

Calcium is excreted in the breast milk. Caution is required and monitoring of mother and baby for any undue effects.

Neonates, infants born prematurely, those with low birth weight, those with an unstable gastrointestinal function or who have serious illnesses may require special consideration. For any infant, if a drug is prescribed to the nursing mother, it should be at the lowest practical dose and for the shortest time. When drug administration is unavoidable and breastfeeding is to continue, minimisation of exposure of the infant to the drug may sometimes be achieved by timing the maternal doses to just after a feeding episode. Infants exposed to drugs via breast milk should be monitored for unusual signs or symptoms. Interactions between the drug received by the infant from the mother's milk and medication prescribed for the infant should also be considered, for example, when the drug given to the infant may prevent metabolism of the drug received via breast milk.
Specialist advice is available from the UK Drugs in Lactation Advisory Service at https://www.midlandsmedicines.nhs.uk/content.asp?section=6&subsection=17&pageIdx=1

Side Effects

Nausea
Vomiting
Hot flushes
Sweating
Hypotension
Bradycardia
Arrhythmias
Vasomotor collapse
Tissue calcification following extravasation
Irritation (injection site)
Peripheral vasodilatation

Presentation

Injection containing the equivalent of 10% of calcium gluconate as calcium gluconate (9.5%) with calcium saccharate (equivalent to 0.5%) in 10ml.

Drugs List

Therapeutic Indications

Uses

Acute hypocalcaemia
Neonatal hypocalcaemia
Tetany - hypocalcaemic
Cardiac resuscitation
Neonatal tetany
Acute colic of lead poisoning
Acute fluoride poisoning (adjunct)
Hypocalcaemia prevention in exchange transfusions
Hyperkalaemia (prevention of arrhythmias)

Dosage

Dosage is variable based on individual clinical and laboratory findings, size of individual and indication.
Normal concentration of calcium in plasma is within the range of 2.25mmol per litre to 2.75mmol per litre or 4.5mEq per litre to 5.5mEq per litre. Treatment should be aimed at restoring or maintaining this level.

If plasma calcium exceeds 2.75mmol per litre or if 24 hour urinary calcium excretion exceeds 5mg/kg, treatment should be discontinued immediately as cardiac arrhythmias may occur at these levels.

Adults

Children

Neonates

Patients with Renal Impairment

Administration

By intravenous injection or by continuous intravenous infusion.

Intravenous injection
Administration rate should not exceed 2ml (0.45mmol of calcium) per minute. For neonates and children see Dosage section.
Monitor for extravasation as irritation and/or possible soft tissue calcification may occur. Where appropriate use the oral route as soon as possible due to the risk of extravasation.

Continuous infusion
Dosage and rate of infusion is variable and depends upon the size of the individual, the indication and the clinical condition.
For children dilute to at least 45micromol/ml with glucose 5% or sodium chloride 0.9%. Maximum administration rate 45micromol/kg/hour (or in neonates maximum 22micromol/kg/hour). May be given more concentrated via a central venous catheter.

Use only if the solution is clear.

Reconstitution

Further dilution into a larger volume should be carried out for all continuous intravenous infusions (see Compatibilities).

Compatibilities

Calcium gluconate injection can be diluted with glucose injection 5% or sodium chloride injection 0.9%.

Incompatibilities

Calcium salts can form complexes with many drugs which may result in a precipitate. Calcium salts are incompatible with oxidising agents, citrates, soluble carbonates, bicarbonates, phosphates, tartrates and sulfates. Physical incompatibility has also been reported with amphotericin, cephalothin sodium, cephazolin sodium, cephamandole nafate, novobiocin sodium, dobutamine hydrochloride, prochlorperazine, and tetracyclines.

In patients of any age ceftriaxone must not be mixed or administered simultaneously with any calcium-containing IV solutions, even via different infusion lines or at different infusion sites.

Care should be taken to avoid admixtures of calcium gluconate and incompatible drugs in giving sets, or in the circulation after separate administration.

Contraindications

Hypercalcaemia e.g. in hyperparathyroidism, hypervitaminosis D or neoplastic disease with decalcification of bone.

Severe hypercalciuria.

Concurrent cardiac glycosides - digitalis intoxication may be precipitated.

Calcium gluconate should not be used for long term or repeated treatment in children under 18 years and those with impaired renal function as aluminium oxide can be leached from the glass ampoules.

Calcium gluconate should not be used in the preparation of total parenteral nutrition especially in those with impaired renal function and in children under 18 to limit the expose to aluminium.

Precautions and Warnings

Use with caution in patients with renal impairment, nephrolithiasis, history of nephrolithiasis and nephrocalcinosis. Manufacturer contraindicates the use of calcium gluconate 10% injection in patients with severe renal impairment. See Dosage - Renal Impairment .

Use with caution in patients with cardiac disorder.

Use with caution in patients with sarcoidosis.

Elderly

Children under 18 years - see Contraindications.

Pregnancy (see Pregnancy section)

Breastfeeding (see Lactation section)

Monitor plasma calcium levels and calcium excretion, especially in children, in chronic renal failure or where there is evidence of calculi formation within urinary tract.

If plasma calcium exceeds 2.75mmol per litre or if 24 hour urinary calcium excretion exceeds 5mg/kg, treatment should be discontinued immediately as cardiac arrhythmias may occur at these levels.

Calcium salts are irritant. Administer carefully and monitor injection site due to risk of extravasation.

Pregnancy and Lactation

Pregnancy

Use only if considered essential by a physician. Caution and close monitoring is required.

The use of all medication in pregnancy should be avoided whenever possible; particularly in the first trimester. Non-drug treatments should also be considered. When essential, a medication with the best safety record over time should be chosen, employing the lowest effective dose for the shortest possible time. Polypharmacy should be avoided. Teratogens taken in the pre-embryonic period, often quoted as lasting until 14-17 days post-conception, are believed to have an all-or-nothing effect. Where drugs have a short half-life, and when the date of conception is certain, this may allow women to be reassured where drug exposure has occurred within this time frame. Further advice may be available from the UK National Teratology Information Service (NTIS) and through ToxBase, available via password on the internet ( www.toxbase.org ) or if this is unavailable at the backup site ( www.toxbasebackup.org ).

Lactation

Calcium is excreted in the breast milk. Caution is required and monitoring of mother and baby for any undue effects.

Neonates, infants born prematurely, those with low birth weight, those with an unstable gastrointestinal function or who have serious illnesses may require special consideration. For any infant, if a drug is prescribed to the nursing mother, it should be at the lowest practical dose and for the shortest time. When drug administration is unavoidable and breastfeeding is to continue, minimisation of exposure of the infant to the drug may sometimes be achieved by timing the maternal doses to just after a feeding episode. Infants exposed to drugs via breast milk should be monitored for unusual signs or symptoms. Interactions between the drug received by the infant from the mother's milk and medication prescribed for the infant should also be considered, for example, when the drug given to the infant may prevent metabolism of the drug received via breast milk.
Specialist advice is available from the UK Drugs in Lactation Advisory Service at https://www.midlandsmedicines.nhs.uk/content.asp?section=6&subsection=17&pageIdx=1

Side Effects

Nausea
Vomiting
Hot flushes
Sweating
Hypotension
Bradycardia
Arrhythmias
Vasomotor collapse
Tissue calcification following extravasation
Irritation (injection site)
Peripheral vasodilatation

Overdosage

It is strongly recommended that the UK National Poisons Information Service be consulted on cases of suspected or actual overdose where there is doubt over the degree of risk or about appropriate management.

The following number will direct the caller to the relevant local centre (0844) 892 0111

Information may be obtained if you have access to ToxBase the primary clinical toxicology database of the National Poisons Information Service. This is available via password on the internet ( www.toxbase.org ) or if this is unavailable at the backup site ( www.toxbasebackup.org ).

Shelf Life and Storage

Store below 25 degrees C.

Further Information

Last Full Review Date: February 2011

Reference Sources

Drug Safety Update: Volume 4, Issue 1, August 2010.

Summary of Product Characteristics: Calcium Gluconate Injection BP. Hameln pharmaceuticals Ltd. Revised April 2020.

The Renal Drug Handbook. 3rd edition. (2009) ed. Ashley, C and Currie, Radcliffe Publishing Ltd, Abingdon.

NICE Evidence Services Available at: www.nice.org.uk Last accessed: 18 November 2022.