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calcium chloride

B05X - I.V. solution additives ATC A12AA03 Small molecule approved 1982 Parenteral

JFDA label: 10% W/V Calcium Gluconate Inj

Mechanism of Action

Moderates nerve and muscle performance via action potential excitation threshold regulation

Indications

Off-label

  • Beta-blocker overdose (shock refractory to other measures)
  • Calcium channel blocker overdose
  • Malignant arrhythmias (including cardiac arrest) associated with hypermagnesemia
  • Severe hyperkalemia

Contraindications

Source: Lexicomp

  • Known or suspected digoxin toxicity Absolute
  • not recommended as routine treatment in cardiac arrest (includes asystole, ventricular fibrillation, pulseless ventricular tachycardia, or pulseless electrical activity) Absolute

Adverse Reactions

Very Common >10%Common 1–10%Uncommon 0.1–1% Rare 0.01–0.1%Very Rare <0.01%Not Known

Cardiac disorders (6)

Not Known Bradycardia · cardiac arrest · cardiac arrhythmia · hypotension · syncope · vasodilatation

Nervous system disorders (2)

Not Known Feeling abnormal (sense of oppression; with rapid IV injection) · tingling sensation (with rapid IV injection)

Renal and urinary disorders (1)

Not Known Nephrolithiasis

Metabolism and nutrition disorders (2)

Not Known Hot flash (with rapid IV injection) · hypercalcemia

Gastrointestinal disorders (3)

Not Known Dysgeusia (chalky taste) · gastrointestinal irritation · increased serum amylase

General disorders and administration site conditions (1)

Not Known Local tissue necrosis (following extravasation)

Other (1)

Not Known Cutaneous calcification

Dosing

Source: Lexicomp

Note: One gram of calcium chloride salt is equal to 270 mg of elemental calcium. Dosages are expressed in terms of the calcium chloride salt based on a solution concentration of 100 mg/mL (10%) containing 1.4 mEq (27 mg)/mL elemental calcium. Hypocalcemia: IV: Acute, symptomatic: Manufacturer's labeling: 200 to 1,000 mg every 1 to 3 days Severe, symptomatic (eg, seizure, tetany): 1,000 mg over 10 minutes; repeat every 60 minutes until symptoms resolve (French 2012) Note: In general, IV calcium gluconate is preferred over IV calcium chloride in nonemergency settings due to the potential for more severe extravasation with calcium chloride. Cardiac arrest or cardiotoxicity in the presence of hyperkalemia, hypocalcemia, or hypermagnesemia: IV: 500 to 1,000 mg over 2 to 5 minutes; may repeat as necessary (AHA [Vanden Hoek, 2010]) Note: Routine use in cardiac arrest is not recommended due to the lack of improved survival (AHA [Neumar 2010]). Beta-blocker overdose (with shock refractory to other measures) (off-label use): Note: Optimal dose has not been established (DeWitt 2004): IV: Initial: 10% solution: 20 mg/kg over 5 to 10 minutes followed by an IV infusion (AHA [Vanden Hoek 2010]; Kerns 2007) IV infusion: 10% solution: 20 to 50 mg/kg/hour titrated to improved blood pressure, contractility; maintain ionized calcium at a goal of twice normal (AHA [Vanden Hoek 2010]; Kerns 2007). Calcium channel blocker overdose (off-label use): Note: Optimal dose has not been established (DeWitt, 2004). IV: Initial: 10% solution: 1,000 to 2,000 mg over 5 minutes; may repeat every 10 to 20 minutes with 3 to 4 additional doses or 1,000 mg every 2 to 3 minutes until clinical effect is achieved (DeWitt 2004); if favorable response obtained, consider IV infusion or 20 mg/kg over 5 to 10 minutes followed by a continuous IV infusion (Kerns 2007). IV infusion: 10% solution: 20 to 50 mg/kg/hour titrated to improved blood pressure and contractility; maintain ionized calcium at a goal of twice normal (Kerns 2007).
(For additional information see "Calcium chloride: Pediatric drug information") Note: One gram of calcium chloride salt is equal to 270 mg of elemental calcium. Dosages are expressed in terms of the calcium chloride salt based on a solution concentration of 100 mg/mL (10%) containing 1.4 mEq (27 mg)/mL elemental calcium. Hypocalcemia: Acute, symptomatic: Manufacturer’s recommendations: Children: IV: 2.7 to 5 mg/kg/dose every 4 to 6 hours Note: In general, IV calcium gluconate is preferred over IV calcium chloride in nonemergency settings due to the potential for more severe extravasation with calcium chloride. Cardiac arrest or cardiotoxicity in the presence of hyperkalemia, hypocalcemia, or hypermagnesemia: Infants and Children: IV, I.O.: 20 mg/kg (maximum: 2,000 mg/dose); may repeat as necessary (AHA [Kleinman, 2010]; Hegenbarth, 2008) Note: Routine use in cardiac arrest is not recommended due to the lack of improved survival (AHA [Kleinman, 2010]). Calcium channel blocker overdose (off-label use): Note: Optimal dose has not been established (DeWitt 2004): Infants and Children: IV, I.O.: Initial: 10 to 20 mg/kg (maximum: 2,000 mg/dose) over 10 to 15 minutes; may repeat every 10 to 15 minutes (AHA [Kleinman, 2010]; Arroyo 2009); if favorable response obtained, consider IV infusion IV infusion: 20 to 50 mg/kg/hour (Arroyo 2009)
Refer to adult dosing.
No initial dosage adjustment necessary; however, 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.

Warnings & Precautions

Source: Lexicomp

Extravasation

Vesicant; ensure proper catheter or needle position prior to and during infusion. Avoid extravasation. Extravasation may result in severe necrosis and sloughing. Monitor the IV site closely. Disease-related concerns:

Acidosis

Use with caution in patients with respiratory acidosis, renal impairment, or respiratory failure; acidifying effect of calcium chloride may potentiate acidosis.

Hyperphosphatemia

Use with caution in patients with severe hyperphosphatemia as elevated levels of phosphorus and calcium may result in soft tissue and pulmonary arterial calcium-phosphate precipitation.

Hypokalemia

Use with caution in patients with severe hypokalemia as acute rises in serum calcium levels may result in life-threatening cardiac arrhythmias.

Hypomagnesemia

Hypomagnesemia is a common cause of hypocalcemia; therefore, correction of hypocalcemia may be difficult in patients with concomitant hypomagnesemia. Evaluate serum magnesium and correct hypomagnesemia (if necessary), particularly if initial treatment of hypocalcemia is refractory.

Renal impairment

Use with caution in patients with chronic renal failure to avoid hypercalcemia; frequent monitoring of serum calcium and phosphorus is necessary. Concurrent drug therapy issues:

Ceftriaxone

Ceftriaxone may complex with calcium causing precipitation. Fatal lung and kidney damage associated with calcium-ceftriaxone precipitates has been observed in premature and term neonates. Due to reports of precipitation reaction in neonates, do not coadminister ceftriaxone with calcium-containing solutions, even via separate infusion lines/sites or at different times in any neonate. Ceftriaxone should not be administered simultaneously with any calcium-containing solution via a Y-site in any patient. However, ceftriaxone and calcium-containing solutions may be administered sequentially of one another for use in patients other than neonates if infusion lines are thoroughly flushed (with a compatible fluid) between infusions.

Digoxin

Use with caution in digitalized patients; hypercalcemia may precipitate cardiac arrhythmias; use is contraindicated with known or suspected digoxin toxicity. 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). See manufacturer’s labeling. Other warnings/precautions:

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.

Duration of use

Avoid metabolic acidosis (ie, administer only up to 2 to 3 days then change to another calcium salt).

IV administration

For IV use only; do not inject SubQ or IM Avoid too rapid IV administration (do not exceed 100 mg/minute except in emergency situations).

Pregnancy & Lactation

Pregnancy

FDA category C Teratogenic

Animal reproduction studies have not been conducted. Calcium crosses the placenta. 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). Information related to use as an antidote in pregnancy is limited. In general, medications used as antidotes should take into consideration the health and prognosis of the mother; antidotes should be administered to pregnant women if there is a clear indication for use and should not be withheld because of fears of teratogenicity (Bailey 2003). Medications used for the treatment of cardiac arrest in pregnancy are the same as in the non-pregnant woman. Doses and indications should follow current Advanced Cardiovascular Life Support guidelines. Appropriate medications should not be withheld due to concerns of fetal teratogenicity (Jeejeebhoy [AHA] 2015).

Lactation

Calcium is excreted in breast milk. The amount of calcium in breast milk is homeostatically regulated and not altered by maternal calcium intake. Calcium requirements are the same in lactating and nonlactating females (IOM 2011).

Monitoring

Clinical pearlSerum calcium and ionized calcium; albumin; serum phosphate; magnesium (to facilitate calcium repletion); ECG when appropriate. Monitor infusion site. Calcium channel blocker overdose, beta-blocker overdose (off-label uses): Monitor hemodynamic response; monitor serum ionized calcium levels every 30 minutes initially then every 2 hours and maintain ionized calcium ~2 times the ULN; avoid severe hypercalcemia (ionized calcium levels >2 times ULN) (Kerns 2007).

Chemistry & Properties

2D structure
FormulaCaCl2
Molecular weight110.98 g/mol
IUPAC namecalcium dichloride
CAS10043-52-4
PubChem CID5284359
InChIKeyUXVMQQNJUSDDNG-UHFFFAOYSA-L
SMILES[Ca+2].[Cl-].[Cl-]

Biology & Pharmacokinetics

Pharmacokinetics

Protein binding40.0%

Drug–drug interactions (34, DDInter)

Interacting drugSeverityManagement
Ceftriaxone major
Digitoxin major
Digoxin major
Amlodipine moderate
Bendroflumethiazide moderate
Benzthiazide moderate
Bepridil moderate
Calcipotriol (topical) moderate
Calcitriol (topical) moderate
Chlorothiazide moderate
Chlorthalidone moderate
Demeclocycline moderate
Diltiazem moderate
Doxycycline moderate
Felodipine moderate
Hydrochlorothiazide moderate
Hydroflumethiazide moderate
Indapamide moderate
Isradipine moderate
Levamlodipine moderate
Metolazone moderate
Minocycline moderate
Nicardipine moderate
Nifedipine moderate
Nimodipine moderate
Nisoldipine moderate
Omadacycline moderate
Oxytetracycline moderate
Polythiazide moderate
Sarecycline moderate
Strontium chloride Sr-89 moderate
Tetracycline moderate
Trichlormethiazide moderate
Verapamil moderate

Registered Products (18)

BrandForm / strengthPackAgentCitizen (JOD)
Mamera Caplet Tablet 1 mg, 30 mcg, 100 mg, 30 IU, 3000 IU, 200 IU, 3 mg, 3.4 mg, 20 mg, 20 mcg, 10 mg, 12 mcg, 200 mg, 25 mcg, 150 mcg, 25 mcg, 22.5 mg, 27 mg, 2 mg, 10 mg, 25 mg, 2.3 mg 30 tab Jordan Sweden Medical & Sterilization Co. 2.420
Cal-C-Vita Tablet 1 g, 300 IU, 15 mg, 250 mg 15 tab The Jordan Drugstore Co 3.860
Pronatal Tablet 0.6 mg, 2.6 mcg, 18 mg, 0.03 mg, 2 mg, 85 mg, 15 mg, 0.06 mg, 150 mg, 0.03 mg, 0.2 mg, 0.05 mg, 11 mg, 1.9 mg, 27 mg, 1 mg, 53 mg, 1.4 mg, 200 IU, 1.4 mg 30 tab THE ARAB DRUG STORE P.S.C 5.570
Pharmaton Capsules Capsule 20 mg, 15 mg, 10 mg, 60 mg, 400 IU, 2 mg, 4000 IU, 1 mcg, 90.3 mg, 1 mg, 10 mg, 1 mg, 10 mg, 40 mg, 10 mg, 1 mg, 2 mg, 8 mg, 66 mg, 1 mg, 26 mg, 70 mg, 0.2 mg 30 cap THE ARAB DRUG STORE P.S.C 6.700
Elevit Pronatal film-coated tablets Film-Coated Tablet 0.80 mg, 4.00 mcg, 19.00 mg, 10.00 mg, 200 mcg, 100.00 mg, 1080 mcg, 12.5 mcg, 125.00 mg, 7.50 mg, 2.60 mg, 60.00 mg, 1.00 mg, 125 mg, 1.00 mg, 1.80 mg, 100.00 mg, 1.60 mg, 15.00 mg 30 tab The Jordan Drugstore Co 8.330
Ultimate DHEA Capsule 25 mg, 70 mg, 90 mg, 50 mg 60 cap Alghad Drug Store 25.000
10% W/V Calcium Gluconate Inj Powder for Injection 10 % 20 amp pack varies THE ARAB DRUG STORE P.S.C —
10%Calcium Gluconate Solution 10 % 10 ml pack varies Sabbagh Drug Store —
Calcium Chloride Ampoule 100 mg/ml 20 amp Khalil ibraheem drug stores —
Calcium Chloride USP IV Ampoule 1 g/10 ml 100 amp مستودع أدوية جاودة الدولي —
Calcium Gluconate Ampoule 9 g, 1.30 g 50 ampoule شركة مستودع ادوية جرينلاند —
Calcium Gluconate USP IV Ampoule 10 g/100 ml 100 amp JAWEDA INT. DRUD STORE —
Calcium Resonium Powder Powder 99.934 % 300 g Ulfa Pharma Co. —
Peritoneal dialysis Tablet 538 mg, 5.08 mg, 25.7 mg, 1.5 mg 2 l مستودع ادوية الثائر —
Peritoneal dialysis Tablet 538 mg, 5.08 mg, 25.7 mg, 2.5 mg 2 l مستودع ادوية الثائر —
Peritoneal dialysis Tablet 538 mg, 5.08 mg, 25.7 mg, 4.25 mg 2 l مستودع ادوية الثائر —
Qatar 10% Calcium Chloride Ampoule 10 % w/v 35 amp شركة مستودع ادوية جرينلاند —
Resical Powder Powder 93.5 % 300 g JORDAN RIVER PHARMA.IND(JORIVER)/JORDAN —