calcitonin

kal-sih-toe-nin

(Calcimar, Caltine  J, Cibacalcin, Fortical, Miacalcin, Miacalcin Nasal)

Do not confuse calcitonin with calcitriol.

G CLASSIFICATION

PHARMACOTHERAPEUTIC: Synthetic hormone. CLINICAL: Calcium regulator, bone resorption inhibitor, osteoporosis therapy.

ACTION

A synthetic hormone that decreases osteoclast activity in bones, decreases tubular reabsorption of sodium and calcium in the kidneys, and increases absorption of calcium in the GI tract. Therapeutic Effect: Regulates serum calcium concentrations.

PHARMACOKINETICS

Injection form rapidly metabolized (primarily in kidneys); primarily excreted in urine. Nasal form rapidly absorbed. Half-life: 70U90 min (injection); 43 min (nasal).

USES

Parenteral: Treatment of Paget's disease, hypercalcemia, postmenopausal osteoporosis, osteogenesis imperfecta. Intranasal: Postmenopausal osteoporosis. OFF-LABEL: Treatment of secondary osteoporosis due to drug therapy or hormone disturbance.

PRECAUTIONS

CONTRAINDICATIONS: Hypersensitivity to gelatin desserts or salmon protein. CAUTIONS: History of allergy, renal dysfunction.

B LIFESPAN CONSIDERATIONS: Pregnancy/Lactation: Drug does not cross placenta; unknown if distributed in breast milk. Safe usage during lactation not established (inhibits lactation in animals). Pregnancy Category C. Children: Safety and efficacy not established. Elderly: No age-related precautions noted.

INTERACTIONS

DRUG: None known. HERBAL: None known. FOOD: None known. LAB VALUES:  None known.

AVAILABILITY (Rx)

INJECTION (MIACALCIN): 200 international units/ml (calcitonin-salmon), 500 mg (calcitonin-human). NASAL SPRAY (FORTICAL, MIACALCIN NASAL): 200 international units/activation (calcitonin-salmon).

ADMINISTRATION/HANDLING

IM/SUBCUTANEOUS

N May be administered subcutaneously or IM. No more than 2-ml dose should be given IM. N Skin test should be performed before therapy in patients suspected of sensitivity to calcitonin. N Bedtime administration may reduce nausea, flushing.

INTRANASAL

N Refrigerate unopened nasal spray. Store at room temperature after initial use. N Instruct patient to clear nasal passages as much as possible. N Tilt head slightly forward, insert spray tip into nostril, pointing toward nasal passages, away from nasal septum. N Spray into nostril while patient holds other nostril closed and concurrently inspires through nose to permit medication as high into nasal passage as possible.

INDICATIONS/ROUTES/DOSAGE

SKIN TESTING BEFORE TREATMENT IN PATIENTS WITH SUSPECTED SENSITIVITY TO CALCITONIN-SALMON

INTRACUTANEOUS: ADULTS, ELDERLY: Prepare a 10-international units/ml dilution; withdraw 0.05 ml from a 200-international units/ml vial in a tuberculin syringe; fill up to 1 ml with 0.9% NaCl. Take 0.1 ml and inject intracutaneously on inner aspect of forearm. Observe after 15 min; a positive response is the appearance of more than mild erythema or wheal.

PAGET'S DISEASE

IM, SUBCUTANEOUS: ADULTS, ELDERLY: Initially, 100 international units/day. Maintenance: 50 international units/day or 50U100 international units every 1U3 days.

INTRANASAL: ADULTS, ELDERLY: 200U400 international units/day.

OSTEOPOROSIS IMPERFECTA

IM, SUBCUTANEOUS: ADULTS: 2 international units/kg 3 times a week.

POSTMENOPAUSAL OSTEOPOROSIS

IM, SUBCUTANEOUS: ADULTS, ELDERLY: 100 international units/day with adequate calcium and vitamin D intake.

INTRANASAL: ADULTS, ELDERLY: 200 international units/day as a single spray, alternating nostrils daily.

HYPERCALCEMIA

IM, SUBCUTANEOUS: ADULTS, ELDERLY: Initially, 4 international units/kg q12h; may increase to 8 international units/kg q12h if no response in 2 days; may further increase to 8 international units/kg q6h if no response in another 2 days.

SIDE EFFECTS

FREQUENT: IM, Subcutaneous (10%): Nausea (may occur 30 min after injection, usually diminishes with continued therapy), inflammation at injection site. Nasal (12%U10%): Rhinitis, nasal irritation, redness, sores. OCCASIONAL: IM, Subcutaneous (5%U2%): Flushing of face or hands. Nasal (5%U3%): Back pain, arthralgia, epistaxis, headache. RARE: IM, Subcutaneous: Epigastric discomfort, dry mouth, diarrhea, flatulence. Nasal: Itching of earlobes, pedal edema, rash, diaphoresis.

ADVERSE REACTIONS/TOXIC EFFECTS

Patients with a protein allergy may develop a hypersensitivity reaction.

NURSING CONSIDERATION

BASELINE ASSESSMENT

Establish baseline electrolytes.

INTERVENTION/EVALUATION

Ensure rotation of injection sites; check for inflammation. Assess vertebral bone mass (document stabilization/improvement). Assess for allergic response: rash, urticaria, swelling, shortness of breath, tachycardia, hypotension.

PATIENT/FAMILY TEACHING

N Instruct patient and family on aseptic technique, proper injection of medication, including rotation of sites. N Nausea is transient and usually decreases with continued therapy. N Notify physician immediately if rash, itching, shortness of breath, significant nasal irritation occur. N Explain to the patient and family that improvement in biochemical abnormalities and bone pain usually occurs in the first few months of treatment. N Explain to patients with neurologic lesions, improvement may take more than a year.

calcium acetate

(PhosLo)

calcium carbonate

(Apo-Cal  J, Calsan  J, Caltrate, Caltrate 600  J, Dicarbosil, Maalox Quick Dissolve, OsCal  J, Os-Cal 500, Titralac, Tums)

calcium chloride

calcium citrate

(Cal-Citrate, Citracal, Citracal Prenatal Rx)

calcium glubionate

(Calcione, Calciquid)

calcium gluconate

kal-see-um

Do not confuse OsCal with Asacol, Citracal with Citrucel, or PhosLo with PhosChol.

G CLASSIFICATION

PHARMACOTHERAPEUTIC: Electrolyte replenisher. CLINICAL: Antacid, antihypocalcemic, antihyperkalemic, antihypermagnesemic, antihyperphosphatemic.

ACTION

An electrolyte that is essential for the function and integrity of the nervous, muscular, and skeletal systems. Calcium plays an important role in normal cardiac and renal function, respiration, blood coagulation, and cell membrane and capillary permeability. It helps regulate the release and storage of neurotransmitters and hormones, and it neutralizes or reduces gastric acid (increase pH). Calcium acetate combines with dietary phosphate to form insoluble calcium phosphate. Therapeutic Effect: Replaces calcium in deficiency states; controls hyperphosphatemia in end-stage renal disease.

PHARMACOKINETICS

Moderately absorbed from the small intestine (absorption depends on presence of vitamin D metabolites and patient's pH). Primarily eliminated in feces.

USES

Parenteral: Acute hypocalcemia (e.g., neonatal hypocalcemic tetany, alkalosis), electrolyte depletion, cardiac arrest (strengthens myocardial contractions), hyperkalemia (reverses cardiac depression), hypermagnesemia (aids in reversing CNS depression). Calcium Carbonate: Antacid, treatment and prevention of calcium deficiency or hyperphosphatemia. Calcium Citrate: Antacid, treatment and prevention of calcium deficiency or hyperphosphatemia. Calcium Acetate: Controls hyperphosphatemia in end-stage renal disease.

PRECAUTIONS

CONTRAINDICATIONS: Calcium renal calculi, digoxin toxicity, hypercalcemia, hypercalciuria, sarcoidosis, ventricular fibrillation. Calcium Acetate: Decreased renal function, hypoparathyroidism. CAUTIONS: Dehydration, history of renal calculi, chronic renal impairment, decreased cardiac function, ventricular fibrillation during cardiac resuscitation.

B LIFESPAN CONSIDERATIONS: Pregnancy/Lactation: Distributed in breast milk. Unknown whether calcium chloride or gluconate is distributed in breast milk. Pregnancy Category C. Children: Extreme irritation, possible tissue necrosis or sloughing with IV. Restrict IV use due to small vasculature. Elderly: Oral absorption may be decreased.

INTERACTIONS

DRUG: Digoxin: May increase the risk of arrhythmias. Etidronate, gallium: May antagonize the effects of these drugs. Ketoconazole, phenytoin, tetracyclines: May decrease the absorption of these drugs. Magnesium (parenteral), methenamine: May decrease the effects of these drugs. HERBAL: None known. FOOD: None known. LAB VALUES: May increase blood pH, and serum gastrin and calcium levels. May decrease serum phosphate and potassium levels.

AVAILABILITY

CALCIUM ACETATE

GELCAP (PHOSLO): 667 mg (equivalent to 169 mg elemental calcium). TABLET (PHOSLO): 667 mg (equivalent to 169 mg elemental calcium).

CALCIUM CARBONATE

TABLETS: equivalent to 500 mg elemental calcium (Os-Cal 500), equivalent to 600 mg elemental calcium (Caltrate 600). TABLETS (CHEWABLE): equivalent to 200 mg elemental calcium (Tums), equivalent to 500 mg elemental calcium (Os-Cal 500), 600 mg (Maalox Quick Dissolve).

CALCIUM CHLORIDE

INJECTION: 10% (100 mg/ml) equivalent to 27.2 mg elemental calcium per ml.

CALCIUM CITRATE

TABLETS: 125 mg (Citracal Prenatal Rx), 250 mg (equivalent to 53 mg elemental calcium) (Cal-Citrate), 950 mg (equivalent to 200 mg elemental calcium) (Citracal).

CALCIUM GLUBIONATE

SYRUP: 1.8 g/5 ml (equivalent to 115 mg of elemental calcium per 5 ml).

CALCIUM GLUCONATE

INJECTION: 10% (equivalent to 9 mg elemental calcium per ml).

ADMINISTRATION/HANDLING

L IV 

Dilution

Calcium chloride N May give undiluted or may dilute with equal amount 0.9% NaCl or sterile water for injection.

Calcium gluconate N May give undiluted or may dilute in up to 1,000 ml NaCl.

Rate of administration

Calcium chloride N Give by slow IV push: 0.5U1 ml/min (rapid administration may produce bradycardia, metallic or chalky taste, drop in BP, sensation of heat, peripheral vasodilation).

Calcium gluconate N Give by IV push: 0.5U1 ml/min (rapid administration may produce vasodilation, drop in BP, arrhythmias, syncope, cardiac arrest). N Maximum rate for intermittent IV infusion is 200 mg/min (e.g., 10 ml/min when 1 g diluted with 50 ml diluent).

Storage N Store at room temperature.

PO

N Take tablets with full glass of water 0.5U1 hr after meals. Give syrup before meals (increases absorption), diluted in juice, water. N Chew chewable tablets well before swallowing.

D IV INCOMPATIBILITIES

Calcium chloride: Amphotericin B complex (Abelcet, AmBisone, Amphotec), propofol (Diprivan), sodium bicarbonate. Calcium gluconate: Amphotericin B complex (Abelcet, AmBisome, Amphotec), fluconazole (Diflucan).

IV COMPATIBILITIES

Calcium chloride: Amikacin (Amikin), dobutamine (Dobutrex), lidocaine, milrinone (Primacor), morphine, norepinephrine (Levophed). Calcium gluconate: Ampicillin, aztreonam (Azactam), cefazolin (Ancef), cefepime (Maxipime), ciprofloxacin (Cipro), dobutamine (Dobutrex), enalapril (Vasotec), famotidine (Pepcid), furosemide (Lasix), heparin, lidocaine, magnesium sulfate, meropenem (Merrem IV), midazolam (Versed), milrinone (Primacor), norepinephrine (Levophed), piperacillin and tazobactam (Zosyn), potassium chloride, propofol (Diprivan).

INDICATIONS/ROUTES/DOSAGE

HYPERPHOSPHATEMIA

PO (CALCIUM ACETATE): ADULTS, ELDERLY: 2 tablets 3 times a day with meals. May increase gradually to bring serum phosphate level to less than 6 mg/dl as long as hypercalcemia does not develop.

HYPOCALCEMIA

PO (CALCIUM CARBONATE): ADULTS, ELDERLY: 1U2 g/day in 3U4 divided doses. CHILDREN: 45U65 mg/kg/day in 3U4 divided doses.

PO (CALCIUM GLUBIONATE): ADULTS, ELDERLY: 6U18 g/day in 4U6 divided doses. CHILDREN, INFANTS: 0.6U2 g/kg/day in 4 divided doses. NEONATES: 1.2 g/kg/day in 4U6 divided doses.

IV (CALCIUM CHLORIDE): ADULTS, ELDERLY: 0.5U1 g repeated q4U6h as needed. CHILDREN: 2.5U5 mg/kg/dose in q4U6h.

IV (CALCIUM GLUCONATE): ADULTS, ELDERLY: 2U15 g/24 hr. CHILDREN: 200U500 mg/kg/day.

ANTACID

PO (CALCIUM CARBONATE): ADULTS, ELDERLY: 1U2 tabs (5U10 ml) in q2h as needed.

OSTEOPOROSIS

PO (CALCIUM CARBONATE): ADULTS, ELDERLY: 1200 mg/day.

CARDIAC ARREST

IV (CALCIUM CHLORIDE): ADULTS, ELDERLY: 2U4 mg/kg. May repeat q10 min. CHILDREN: 20 mg/kg. May repeat in 10 min.

HYPOCALCEMIA TETANY

IV (CALCIUM CHLORIDE): ADULTS, ELDERLY: 1 g may repeat in 6 hr. CHILDREN: 10 mg/kg over 5U10 min. May repeat in q6U8h.

IV (CALCIUM GLUCONATE): ADULTS, ELDERLY: 1U3 g until therapeutic response achieved. CHILDREN: 100U200 mg/kg/dose in 6U8 hr.

SUPPLEMENT

PO (CALCIUM CITRATE): ADULTS, ELDERLY: 0.5U2 g 2U4 times a day.

SIDE EFFECTS

FREQUENT: PO: Chalky taste. Parenteral: Hypotension; flushing; feeling of warmth; nausea; vomiting; pain, rash, redness, or burning at injection site; diaphoresis. OCCASIONAL: PO: Mild constipation, fecal impaction, peripheral edema, metabolic alkalosis (muscle pain, restlessness, slow breathing, altered taste). Calcium Carbonate: Milk-alkali syndrome (headache, decreased appetite, nausea, vomiting, unusual tiredness). RARE: Difficult or painful urination.

ADVERSE REACTIONS/TOXIC EFFECTS

Hypercalcemia is a serious adverse effect of calcium acetate use. Early signs include constipation, headache, dry mouth, increased thirst, irritability, decreased appetite, metallic taste, fatigue, weakness, and depression. Later signs include confusion, somnolence, hypertension, photosensitivity, arrhythmias, nausea, vomiting, and increased painful urination.

NURSING CONSIDERATION

BASELINE ASSESSMENT

Assess BP, EKG and cardiac rhythm, renal function, serum magnesium, phosphate, potassium concentrations.

INTERVENTION/EVALUATION

Monitor BP, EKG, cardiac rhythm, serum magnesium, phosphate, potassium, renal function. Monitor serum, urine calcium concentrations. Monitor for signs of hypercalcemia.

PATIENT/FAMILY TEACHING

N Stress importance of diet. N Take tablets with full glass of water, ½ U1 hr after meals. N Give liquid before meals. N Do not take within 1U2 hr of other oral medications, fiber-containing foods. N Avoid excessive alcohol, tobacco, caffeine.