Calcium Supplements

Tums: Do not take more than 15 tablets in a 24-hour period or use the maximum dosage of this product for more than 2 weeks, except under the advice and supervision of a physician. If symptoms persist for 2 weeks, stop using this product and see a physician. Keep this and all drugs out of the reach of children.
Tums E-X: Do not take more than 10 tablets in a 24-hour period or use the maximum dosage of this product for more than two weeks, except under the advice and supervision of a physician. If symptoms persist for two weeks, stop using this product and see a physician. Keep this and all drugs out of the reach of children.
Tums ULTRA: Do not take more than 7 tablets in 24-hour period or use the maximum dosage of this product for more than two weeks, except under the advice and supervision of a physician. If symptoms persist for two weeks, stop using and see a physician. Keep this and all drugs out of the reach of children.

Dosage and Administration:
Tums: Chew 2-4 tablets as symptoms occur. Repeat hourly if symptoms return, or as directed by physician. Tums E-X: Chew 2-4 tablets as symptoms occur. Repeat hourly if symptoms return, or as directed by a physician. Tums ULTRA: Chew 2-3 tablets as symptoms occur. Repeat hourly if symptoms return, or as directed by a physician.

DIRECTIONS: Chew 2 tablets twice daily.

Normal values: Total Calcium: 8.4-10.2 mg/dl (2.1-2.6 mmol/L). Ionized Calcium: 3.8-5.3 mg/dl (0.95-1.35 mmol/L). Protein binding: Moderate, approximately 45% in plasma.

1. Correct for hypoalbuminemia: If albumin is < 2, check ionized Ca++. Note that alkalosis augments Ca++ binding to albumin, decreasing the amount of ionized (effective) Ca++ and increasing severity of symptoms at a given level.
2. Determine Ca x PO4 product in mg/dl before administering calcium. If product is greater than 60 mg/dl, there is an increased risk of calcium phosphate precipitation in the cornea, lung, kidney, cardiac conduction system, and blood vessels.
3. Other: a) Correct hypomagnesemia. Determine potassium, phosphorus and magnesium levels. If the magnesium concentration is low, it should be corrected, otherwise it will be difficult to normalize potassium and calcium.Hyperkalemia and hypomagnesemia potentiate the cardiac neuromuscular irritability produced by hypocalcemia. Hypokalemia and hypermagnesemia protect against the effects of hypocalcemia. b) Beware that treatment of concomitant metabolic acidosis may further reduce ionized calcium level because both hydrogen ions and calcium are bound to albumin. As acidosis is corrected, hydrogen ions dissociate from albumin, allowing calcium to bind to albumin and further reducing the ionized calcium level.

4. Treatment:

Oral: CaCO3 500-1000 mg TID between (after) meals (to maximize absorption). Also consider vitamin D in patients with renal failure.

IV: max 10 mEq/hour. Symptomatic hypocalcemia (See signs above) — Patients should be treated immediately. Many patients have symptoms when their serum ionized calcium conc is < 2.8 mg/dL (0.7 mmol/L), or their serum total calcium conc (corrected) is ~ 7 to 7.5 mg/dL (1.8 mmol/L).

The most appropriate treatment, unless hypomagnesemia is documented, is intravenous calcium, in the form of 100 to 200 mg (2.5 to 5 mmol) of elemental calcium (1 to 2 grams of calcium gluconate) in 10 to 20 minutes. The calcium should not be given more rapidly, because of the risk of serious cardiac dysfunction, including systolic arrest. Such infusions do not raise the serum calcium concentration for more than two to three hours, and therefore should be followed by a slow infusion of calcium. The dose should be 0.5 to 1.5 mg/kg per hour. Either 10% CaGluc (93 mg [2.25 mmol] elemental Ca++/ 10 ml amp) or 10% CaCL (272 mg [6.75 mmol] elemental Ca++/ 10 ml amp) can be used, with the following recommendations: The calcium should be diluted in dextrose and water or saline, because concentrated calcium solutions are irritating to veins. Calcium gluconate is usually preferred to calcium chloride because it is less likely to cause tissue necrosis if extravasated.

Summary:
Calcium: (hypocalcemia):
Oral: ~1-2 grams/day (elemental Ca++) in 2-4 divided doses with food.
Example: CaCO3 500mg (200mg Ca++): 1-2 tabs qid.
IV: Symptomatic + corrected total < ~ 7 to 7.5 mg/dL. 1-2 grams CaGluc over 10-20 min x 1, then 0.5 to 1.5 mg/kg/hr elemental calcium. 70kg patient (1 mg/kg/hr) = 0.75g CaGluc/hour. Total calcium will increase ~ 0.5 mg/dl /gram of CaGluc given. Target level: 8 mg/dl.