StatPearls [Internet].
Persevering with Training Exercise
Calcium carbonate is an inorganic salt primarily used within the administration and remedy of low calcium situations, GERD, CKD, and quite a lot of different indicated situations. It’s labeled as a calcium complement, antacid, and as a phosphate binder. This exercise outlines the numerous indications, actions, and contraindications for calcium carbonate as a precious agent within the remedy of osteoporosis, hypothyroidism, rheumatoid arthritis, many different situations or problems that decrease serum calcium ranges. This exercise will spotlight the mechanism of motion, adversarial occasion profile, and different key components (e.g., off-label makes use of, dosing, pharmacodynamics, pharmacokinetics, monitoring, related interactions) pertinent for members of the healthcare crew within the care of sufferers with low serum calcium, GERD, CKD, and associated situations.
Goals:Determine the mechanisms of motion of calcium carbonate.Describe some doable adversarial results of calcium carbonate.Evaluation the suitable monitoring and toxicity of calcium carbonate.Summarize interprofessional crew methods for enhancing care coordination and communication to advance calcium carbonate and enhance outcomes.Earn persevering with schooling credit (CME/CE) on this subject.
Indications
Calcium carbonate, chemically CaCO3, is a resonance-stabilized inorganic salt therapeutically used as a meals additive, a dietary complement, an antacid, and phosphate binder. Calcium carbonate is among the many most considerable compounds discovered within the earth’s crust and generally present in natural substances, reminiscent of egg and oyster shells, crustaceans exoskeletons, and darkish leafy greens, reminiscent of broccoli and kale.[1] Calcium carbonate makes use of prolong past drugs. Calcium carbonate has industrial makes use of as filler in paint, paper, fireplace extinguishers, and adhesives, a element of agricultural and mining mud, an ingredient in family cleaners, as a meals coloring compound, and as an ingredient in cosmetics.[1] In prescription drugs, calcium carbonate is a meals additive used for dietary advantages, is a calcium complement used to deal with low serum calcium situations, is an antacid for gastrointestinal illnesses, is a phosphate binder for persistent kidney illness, and is a tableting excipient used within the making of different pharmaceutical brokers and foodstuffs.[1][2]
Calcium carbonate is indicated for low serum calcium situations, reminiscent of osteoporosis, osteomalacia, hypothyroidism, hypoparathyroidism, pseudohypoparathyroidism, DiGeorge syndrome, kidney dysfunction, pancreatitis, rheumatoid arthritis, Fanconi syndrome, being pregnant, nursing moms, post-menopausal ladies, and whereas utilizing sure drugs.[2][3][4][5][6][7][8] The drugs that require concurrent calcium complement use embody:[9][10][11]
As an antacid, calcium carbonate is indicated to be used in heartburn attributable to gastroesophageal reflux illness (GERD), NSAID higher gastrointestinal mucosal harm, duodenal and gastric ulcers, biliary reflux, stress gastritis exocrine pancreatic insufficiency, bile acid-mediated diarrhea, Non-ulcer dyspepsia, and urinary alkalization.[1][2][12][13][14] Like aluminum and magnesium salts, calcium carbonate will increase intestine motility and in addition has indications to be used in constipation remedy.[12][15]
Calcium carbonate can be indicated to be used within the remedy of hyperphosphatemia seen in persistent kidney illness, as a phosphate binder, as a method of treating overdose by inflicting urinary alkalization, and as a prophylactic remedy in pregnant sufferers earlier than delivery to forestall aspiration pneumonitis.[12][14][16][17]
New analysis means that the indications for calcium carbonate might also embody most cancers remedy by utilizing calcium dietary supplements to deal with colorectal adenomas and utilizing rare-earth-doped calcium carbonate with cerium to kill tumor cells by way of X-ray induced photodynamic remedy.[18][19]
Mechanism of Motion – “t calcium carbonate”
Calcium is of course current within the physique. Many of the physique’s saved calcium is throughout the bones and tooth, as hydroxyapatite. The remainder of the physique’s calcium is in blood, extracellular fluid, muscle, and different physique tissues.[20] Within the blood, 40% of calcium is certain to albumin, 13% binds to an anion, like phosphate and lactate, and the bulk, 47% is free, unbound, ionized calcium (Ca2+).[1][20] The quantity of ionized calcium discovered within the blood is essential and tightly regulated by homeostatic controls as a result of it’s physiologically energetic and performs an important function within the mobile processes of excitable tissues, reminiscent of blood vessels, muscle groups, glands, and nerves.[1][10][20]
Calcium absorption happens within the small gut by energetic transport depending on Vitamin D and diffusion.[1] The fractional calcium absorption, the quantity of calcium absorbed over the quantity ingested, adjustments all through life, being highest in infancy, early puberty, and final two trimesters of being pregnant for girls and steadily declining as a person progresses into previous age with a marked lower beginning after menopause for girls and late ’50s for males.[20]
Calcium carbonate has three separate mechanisms of motion which have pharmacologic results. Calcium impacts the abdomen, small gut, and blood.[21]
As an antacid, calcium carbonate neutralizes gastric acid by performing as a buffer within the abdomen’s acidic setting. When CaCO3 enters the abdomen, it dissociates into ionized calcium (Ca2+) and a carbonate anion (CO32-). The carbonate anion will then bind to the free protons (H+) discovered within the abdomen to extend the pH, by reducing the focus of hydrogen ions within the abdomen. By rising the pH within the abdomen, pepsin, bile acids, and the toxins of Helicobacter pylori grow to be inhibited.[22]
The inhibition of pepsin, an enzyme that may degrade tissue protein, and inhibition of bile acid helps scale back harm to and promote the therapeutic of ulcers within the mucosal lining of the abdomen and duodenum and harm to the esophagus attributable to GERD.[22] There may be nonetheless some criticism concerning the ulcer-healing results of calcium carbonate being solely as a consequence of its acid-neutralizing mechanism as a result of calcium carbonate may cause acid rebound by rising plasma gastrin ranges and has been proven to extend prostaglandins PGE2 and PGF2 after long run use which will clarify an alternate mechanism to ulcer therapeutic.[14][23][24][25]
As an antacid, calcium carbonate additionally will increase gastrointestinal motility and initiates peristalsis.[15][26] When the calcium carbonate is chewed and partially digested, the free calcium stimulates peristalsis within the esophagus to maneuver the acid into the abdomen and reduce heartburn signs.[26]
As a phosphate binder and drug chelator, calcium carbonate works within the small intestines. In people with hyperphosphatemia or overdose, calcium will bind to kind an insoluble compound blocking dietary phosphate or extra drug absorption and excreting it in feces.[1] Moreover, calcium carbonate used as a calcium complement additionally acts within the small gut by chelating with oxalate to forestall absorption and renal calculi formation.[1]
Lastly, calcium carbonate additionally works within the blood to deal with or forestall detrimental calcium steadiness seen in low serum calcium situations.[1] After being absorbed within the small intestines actively with the assistance of vitamin D and passively by way of diffusion, ionized calcium circulates within the blood.
Administration
Manufacturing, Bioavailability, and Absorption
Calcium carbonate is available in pill, chewable, oral suspension, or powder kind. Tablets ought to be swallowed whereas consuming a full glass of water. The oral suspension ought to be properly shaken earlier than measuring the dose, to make sure the ingestion of the right quantity. The bioavailability of calcium from calcium carbonate is increased as a powder.[27] Though calcium citrate has increased bioavailability of calcium than calcium carbonate, in meals fortified with calcium, calcium carbonate permits for higher absorption than different calcium fortification compounds.[1][27][28]
Dosing will depend on the indicated situation and affected person age. For grownup use for heartburn, dosing exceeds 1 gram (1000 mg), however mustn’t exceed 7 grams in a day. For grownup use for calcium supplementation, 1 to 1.2 grams could also be taken orally per day, divided, and brought at meals. For adults with hyperphosphatemia, 1.5 to three grams per day successfully achieves optimum phosphate management in 65% of sufferers.[29] If the affected person misses a daily dose, they need to take it once they keep in mind it, until it’s near the following dose. On the time of the following dose, they need to take the common dose, and never double the dose.
Past age and type of calcium carbonate, absorption of calcium will be affected by the dose given, pH of the abdomen, dimension of the affected person, estrogen standing, vitamin D stage, and genetic polymorphisms.[1][12] The fractional absorption is highest at 500 mg when taken with meals, and the abdomen is acidic.[1][4][30] Fractional absorption additionally will increase when the particular person has adequate vitamin D, doesn’t have an absorption dysfunction, is younger, has extra estrogen, and has a bigger physique dimension.[1][4][30] Absorption of calcium carbonate decreases if a person has a mucosal lining dysfunction or achlorhydria.[31]
Distribution, Metabolism, and Elimination
As beforehand talked about, calcium storage within the physique is primarily in bones and tooth. Nonetheless, within the blood, many of the calcium is discovered because the ionized, physiologically energetic kind. Calcium carbonate is just not metabolized within the conventional pharmacokinetic sense. Calcium carbonate is excreted within the feces as unabsorbed calcium carbonate, within the urine relying on glomerular filtration and renal tubule reabsorption managed by parathyroid hormone (PTH) and Vitamin D, and as carbon dioxide from the lungs.[1]
Being pregnant and Breast Feeding
Calcium can journey by means of the placenta and into breast milk throughout nursing. Calcium carbonate is protected to make use of for pregnant sufferers who’ve GERD, for aspiration prophylaxis earlier than labor, and for nursing.[2][13]
Storage and Drug Interactions
Calcium carbonate ought to be saved at room temperature and never frozen or uncovered to warmth.[13] Calcium carbonate shouldn’t be administered with different medication recognized to lower its absorption, reminiscent of histamine-2 receptor antagonists, glucocorticoids, and thiazide diuretics, however reasonably rescheduled to be taken at separate instances.[1][32] Conversely, vitamin D will improve the absorption of calcium carbonate if coadministered, and sufferers are inspired to take them collectively.[1][4]
Moreover, calcium carbonate will restrict many medication’ effectiveness if taken collectively by rising abdomen pH and reducing their absorption.[12] These medication embody bisphosphonates, fluoroquinolones, tetracyclines, thyroid hormones, proton-pump-inhibitors, reminiscent of omeprazole, iron, and anti-arrhythmic medication like verapamil.[1][12][33] Calcium carbonate also can work together with the excretion of many medication because it causes urine alkalization and can quicken the excretion of medicine that exist as weak acids and lengthen the excretion of medicine that exist as weak bases within the blood.[12]
Hostile Results
Because of the brief time period, periodic nature of calcium carbonate/antacid use, and the small dose of calcium carbonate used for supplementation, most adversarial results are minor. Nonetheless, if massive doses are taken for an prolonged time or abused, overdose can happen. The average to extreme unwanted side effects of overdose embody:[34][35][36][37][38][39]
Milk-alkali syndrome was traditionally a way more frequent extreme aspect impact.[34] Milk-alkali syndrome outcomes from hypercalciuria, and alkaluria predisposing renal calculi and inflicting sequelae reminiscent of pancreatitis and acute renal failure.[34]
Widespread Aspect Results:[2]
Further side-effects happen in people taking calcium carbonate as a phosphate binder for the remedy of hyperphosphatemia, together with calcification of vascular tissues and dying.[29]
“t calcium carbonate”