Calcium Carbonate

A02A - Antacids ATC A02AC01 Small molecule approved 2000 Oral

JFDA label: RENNIE TAB

Mechanism of Action

As dietary supplement, used to prevent or treat negative calcium balance; in osteoporosis, it helps to prevent or decrease the rate of bone loss. Calcium is an integral component of the skeleton and also moderates nerve and muscle performance and allows normal cardiac function. Also used to treat hyperphosphatemia in patients with chronic kidney disease by combining with dietary phosphate to form insoluble calcium phosphate, which is excreted in feces. Calcium salts as antacids neutralize gastric acidity resulting in increased gastric and duodenal bulb pH; they additionally inhibit proteolytic activity of pepsin if the pH is increased >4 and increase lower esophageal sphincter tone (IOM, 2011).

Indications

Approved

Antacid
Calcium supplementation

Off-label

Hyperphosphatemia in chronic kidney disease

Contraindications

Source: Lexicomp

Hypersensitivity to any component of the formulation Absolute

Adverse Reactions

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

Nervous system disorders (2)

Common Headache · laxative effect

Metabolism and nutrition disorders (3)

Common Hypercalcemia · hypophosphatemia · milk-alkali syndrome (with very high, chronic dosing and/or renal failure [headache, nausea, irritability, and weakness or alkalosis, hypercalcemia, renal impairment])

Gastrointestinal disorders (8)

Common Abdominal pain · anorexia · constipation · flatulence · hyperacidity (acid rebound) · nausea · vomiting · xerostomia

Dosing

Source: Lexicomp

Note: One gram of calcium carbonate is equal to 400 mg of elemental calcium. Dosage is in terms of calcium carbonate except where noted; calcium carbonate generally provides approximately 40% elemental calcium: Calcium supplementation: Oral: 500 mg to 4 g daily in 1 to 3 divided doses Antacid: Oral: Generally, 1 to 4 tablets as symptoms occur; maximum: 8,000 mg daily for up to 2 weeks; OTC dosing recommendations may vary by product and/or manufacturer; specific product labeling should be consulted Hyperphosphatemia in chronic kidney disease (off-label use): Total dose of elemental calcium (including dietary sources and calcium-based phosphate binders) should not exceed 2000 mg daily (Eknoyan 2003).

(For additional information see "Calcium carbonate: Pediatric drug information") Note: One gram of calcium carbonate is equal to 400 mg of elemental calcium. Dosage is in terms of calcium carbonate, except where noted; calcium carbonate generally provides approximately 40% elemental calcium: Antacid: Oral: Children 2 to 5 years (10.9 to 21.3 kg): 375 to 400 mg as symptoms occur; maximum: 1,500 mg daily for up to 2 weeks; OTC dosing recommendations may vary by product and/or manufacturer; specific product labeling should be consulted. Children 6 to11 years (≥21.8 kg): 750 to 800 mg as symptoms occur; maximum: 3,000 mg daily for up to 2 weeks; OTC dosing recommendations may vary by product and/or manufacturer; specific product labeling should be consulted. Children ≥12 years and Adolescents: 500 to 3,000 mg as symptoms occur for up to 2 weeks; maximum daily dose: 7,500 mg/day; OTC dosing recommendations may vary by product and/or manufacturer; specific product labeling should be consulted. Calcium supplementation: Oral: Children 2 to 4 years: 750 mg twice daily Children ≥4 years and Adolescents: 750 mg 3 times daily

Refer to adult dosing.

There are no dosage adjustments provided in the manufacturer's labeling (has not been studied).

Warnings & Precautions

Source: Lexicomp

Gastrointestinal effects

Constipation, bloating, and gas are common with calcium supplements (especially carbonate salt) (IOM, 2011).

Hypercalcemia

Chronic hypercalcemia may result in vascular calcification and other soft-tissue calcification (IOM, 2011). Disease-related concerns:

Achlorhydria

Calcium absorption is impaired in achlorhydria; administration is followed by increased gastric acid secretion within 2 hours of administration especially with high doses. Common in the elderly, use an alternate salt (eg, citrate) and administer with food (IOM, 2011; Recker, 1985).

Hypoparathyroid disease

Hypercalcemia and hypercalciuria are most likely to occur in hypoparathyroid patients receiving high doses of vitamin D.

Kidney stones (calcium-containing)

Use caution when administering calcium supplements to patients with a history of kidney stones (IOM, 2011).

Renal insufficiency

Use with caution as these patients are more sensitive or susceptible to the effects of excess calcium (IOM, 2011). Concurrent drug therapy issues:

Drug-drug interactions

Potentially significant interactions may exist, requiring dose or frequency adjustment, additional monitoring, and/or selection of alternative therapy. Consult drug interactions database for more detailed information.

Vitamin D

It is recommended to concomitantly administer vitamin D for optimal calcium absorption when used for the treatment or prevention of conditions related to bone health (eg, osteoporosis). 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.

Pregnancy & Lactation

Pregnancy

FDA category A

Safe

WHO recommends 1.5–2 g/day calcium supplementation for pre-eclampsia prevention in populations with low dietary calcium intake

Lactation

Use with Caution

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). Calcium-based antacids are probably compatible with breast-feeding (Mahadevan, 2006).

Monitoring

Clinical pearl	Monitor plasma calcium levels if using calcium as an electrolyte supplement for deficiency or as treatment of hyperphosphatemia.

Chemistry & Properties

Formula	CCaO3
Molecular weight	100.09 g/mol
IUPAC name	calcium carbonate
CAS	471-34-1
PubChem CID	10112
InChIKey	`VTYYLEPIZMXCLO-UHFFFAOYSA-L`

SMILES

O=C([O-])[O-].[Ca+2]

Biology & Pharmacokinetics

Pharmacokinetics predicted

Bioavailability	10.0%
Half-life	6.433 h
Volume of distribution	0.874 L/kg
Protein binding	15.9%
BBB penetrant	No

Transporters

BCRP (Inhibitor)BSEP (Inhibitor)MRP1 (Inhibitor)OATP1B1 (Inhibitor)OATP1B3 (Inhibitor)P-gp (Inhibitor)P-gp (Substrate)

Drug–drug interactions (100+, DDInter)

Interacting drug	Severity	Management
Bictegravir	major
Dolutegravir	major
Erdafitinib	major
Patiromer	major
Raltegravir	major
Selpercatinib	major
Tolevamer	major
Acalabrutinib	moderate
Acebutolol	moderate
Acetohexamide	moderate
Acetylsalicylic acid	moderate
Alendronic acid	moderate
Amlodipine	moderate
Amphetamine	moderate
Amprenavir	moderate
Atazanavir	moderate
Atenolol	moderate
Atropine	moderate
Bacampicillin	moderate
Baloxavir marboxil	moderate
Bendroflumethiazide	moderate
Benzphetamine	moderate
Benzthiazide	moderate
Bepridil	moderate
Betaxolol	moderate
Bisacodyl	moderate
Bisoprolol	moderate
Bosutinib	moderate
Cabotegravir	moderate
Calcipotriol (topical)	moderate
Calcitriol (topical)	moderate
Carteolol	moderate
Carvedilol	moderate
Cefditoren	moderate
Cefpodoxime	moderate
Cefuroxime	moderate
Ceritinib	moderate
Chloroquine	moderate
Chlorothiazide	moderate
Chlorpropamide	moderate

Showing 40 of 100+.

Registered Products (14)

Brand	Form / strength	Pack	Agent	Citizen (JOD)
Cirkulin Antacid	Lozenge 500 mg	40 Lozenges	AL THARAA FOR PHARMACEUTICALS AND MEDICINE TRADING CO(BEIT LEHEM DRUG STORE))	1.590
Vixon	Solution 267 mg/10 ml, 160 mg/10 ml, 500 mg/10 ml	190 ml	Dar Al Dawa Development and Investment Co Ltd/Jordan	1.620
Algicid Suspension	Suspension 2.67 %, 1.6 %, 5 %	200 ml	PHILADELPHIA PHAEMACEUTICALS.COMP/JORDAN	1.700
Gaviscon Extra Strength 500 peppermint	Tablet 160 mg, 500 mg, 267 mg	12 tab pack varies	Nairoukh Drug Store	1.740
RENNIE TAB	Tablet 680 mg, 80 mg	96 tab	The Jordan Drugstore Co	2.160
Lima	Tablet 500 mg	60 tab	Dar Al Dawa Development and Investment Co Ltd/Jordan	2.200
Gaviscon Peppermint Liquid Relief	Suspension 133.5 mg/5 ml, 80 mg/5 ml, 250 mg/5 ml	200 ml	Nairoukh Drug Store	2.340
Atlast Liquid	Solution 2.67 g/100 ml, 1.60 g/100 ml, 5.00 g/100 ml	200 ml	JERASH PHARMACEUTICALS LTD.CO/JORDAN	2.380
Gaviscon Aniseed	Solution 267 mg/10 ml, 160 mg/10 ml, 500 mg/10 ml	200 ml	Nairoukh Drug Store	2.800
Lima	Tablet 750 mg	60 tab	Dar Al Dawa Development and Investment Co Ltd/Jordan	2.800
Gaviscon Extra Strength 500 peppermint	Tablet 160 mg, 500 mg, 267 mg	24 tab pack varies	Nairoukh Drug Store	3.300
Tums Extra Strength 750 Assorted Fruits	Tablet 750 mg	48 tab	Sukhtian Group	3.470
Gaviscon Double Action Liquid Sachets, Oral Suspension	Suspension Sodium Bicarbonate 213 mg/10 ml, Calcium Carbonate 325 mg/10 ml, Sodium Alginate 500 mg/10 ml	(12 SAC)	Awtar Pharmaceutical Co	5.300
Gaviscon Double Action Mint Liquid suspension	Suspension Sodium Bicarbonate 213 mg/10 ml, Sodium Alginate 500 mg/10 ml, Calcium Carbonate 325 mg/10 ml	300 ml	Nairoukh Drug Store	5.340