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Ion-K


Ion-K may be available in the countries listed below.

Ingredient matches for Ion-K Potassium Gluconate

Potassium Gluconate is reported as an ingredient of Ion-K in the following countries:

Colombia

International Drug Name Search


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zinc gluconate


Generic Name: zinc gluconate (ZINK GLUE koe nate)
Brand names: Orazinc, Orazinc 110(obsolete)

What is zinc gluconate?

Zinc is a naturally occurring mineral. Zinc is important for growth and for the development and health of body tissues.

Zinc gluconate is used to treat and to prevent zinc deficiency.

Zinc gluconate may also be used for other purposes not listed in this medication guide.

What is the most important information I should know about zinc gluconate?

Before using zinc gluconate, talk to your doctor, pharmacist, herbalist, or other healthcare provider. You may not be able to use zinc gluconate if you have certain medical conditions.

Avoid taking this medication with foods that are high in calcium or phosphorus, which can make it harder for your body to absorb zinc gluconate. Foods high in calcium or phosphorus include milk, cheese, yogurt, ice cream, dried beans or peas, lentils, nuts, peanut butter, beer, cola soft drinks, and hot cocoa.

Zinc gluconate can make certain antibiotics less effective. Tell your doctor about all other medications you are using before you start taking zinc gluconate.

What should I discuss with my healthcare provider before taking zinc gluconate?

Before using zinc gluconate, talk to your doctor, pharmacist, herbalist, or other healthcare provider. You may not be able to use zinc gluconate if you have certain medical conditions.

It is not known whether zinc gluconate will harm an unborn baby. Do not take zinc gluconate without telling your doctor if you are pregnant or could become pregnant during treatment. It is not known whether zinc gluconate passes into breast milk or if it could harm a nursing baby. Do not use this medication without telling your doctor if you are breast-feeding a baby. How should I take zinc gluconate?

Use exactly as directed on the label, or as prescribed by your doctor. Do not use in larger or smaller amounts or for longer than recommended.

Take zinc gluconate with a full glass of water. Take zinc gluconate with food if it upsets your stomach.

Your healthcare provider may occasionally change your dose to make sure you get the best results from zinc gluconate. The recommended dietary allowance of zinc gluconate increases with age. Follow your healthcare provider's instructions. You may also consult the National Academy of Sciences "Dietary Reference Intake" or the U.S. Department of Agriculture's "Dietary Reference Intake" (formerly "Recommended Daily Allowances" or RDA) listings for more information.

Store at room temperature away from moisture and heat. What happens if I miss a dose?

Skip the missed dose if it is almost time for your next scheduled dose. Do not use extra medicine to make up the missed dose.

What happens if I overdose? Seek emergency medical attention or call the Poison Help line at 1-800-222-1222.

Overdose symptoms may include nausea, severe vomiting, dehydration, and restlessness.

What should I avoid while taking zinc gluconate? Avoid taking this medication with foods that are high in calcium or phosphorus, which can make it harder for your body to absorb zinc gluconate. Foods high in calcium or phosphorus include milk, cheese, yogurt, ice cream, dried beans or peas, lentils, nuts, peanut butter, beer, cola soft drinks, and hot cocoa. Zinc gluconate side effects Get emergency medical help if you have any of these signs of an allergic reaction: hives; difficulty breathing; swelling of your face, lips, tongue, or throat.

Less serious side effects may include:

nausea; or

upset stomach.

This is not a complete list of side effects and others may occur. Call your doctor for medical advice about side effects. You may report side effects to FDA at 1-800-FDA-1088.

Zinc gluconate Dosing Information

Usual Adult Dose for Dietary Supplement:

Dosage: 105 mg to 350 mg daily.

What other drugs will affect zinc gluconate?

The following drugs can interact with or be made less effective by zinc gluconate. Tell your doctor if you are using any of these:

a blood thinner such as warfarin (Coumadin);

methyltestosterone (Android, Methitest, Oreton);

penicillamine (Cuprimine, Depen);

risedronate (Actonel);

a tetracycline antibiotic such as demeclocycline (Declomycin), doxycycline (Adoxa, Doryx, Oracea, Vibramycin), minocycline (Dynacin, Minocin, Solodyn, Vectrin), or tetracycline (Brodspec, Panmycin, Sumycin, Tetracap); or

an antibiotic such as ciprofloxacin (Cipro), ofloxacin (Floxin), norfloxacin (Noroxin), levofloxacin (Levaquin), and others.

This list is not complete and other drugs may interact with zinc gluconate. Tell your healthcare provider about all medications you use. This includes prescription, over-the-counter, vitamin, and herbal products. Do not start a new medication without telling your doctor.

More zinc gluconate resources Zinc gluconate Side Effects (in more detail) Zinc gluconate Use in Pregnancy & Breastfeeding Zinc gluconate Drug Interactions Zinc gluconate Support Group 0 Reviews for Zinc gluconate - Add your own review/rating Orazinc MedFacts Consumer Leaflet (Wolters Kluwer) Compare zinc gluconate with other medications Dietary Supplementation Where can I get more information? Your pharmacist can provide more information about zinc gluconate.

See also: zinc gluconate side effects (in more detail)


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Gelato Chlorhexidine Rinse


Generic Name: chlorhexidine gluconate
Dosage Form: oral rinse
Gelato Chlorhexidine Distilled Water, Glycerin, Polysorbate 20, Poloxamer 407, Sodium Saccharin, Mint Flavor, FD and C Blue #1

The effect of Chlohexidrine Gluconate Oral Rinse on periodontitis has not been determined. An increase in supragingival calculus was not noted in clinical testing in chlohexidine gluconate oral rinse users compared with control users. It is not known if Chlorhexidine Gluconate oral rinse use results in an increase in subgingival calculus. Calculus deposits should be removed by a dental prophylaxis at intervals not greater than six months. Hypersensitivity and generalized allergic reactions have occured. read CONTRAINDICATIONS indicated on the insert inside the box.

To open, press down while turning cap. To seal, turn until cap clicks and is tight. Fill dosage cup to the fill like (150ml). Swish in your mouth undiluted for 30 seconds, the spit out. Use after breakfast and before bedtime. Or, use as prescribed by your dentist.

Chlorhexidine Gluconate Oral Rinse is indicated for use between dental visits as part of a professional program for the treatment of gingivitis as characterized by redness and swelling of the gingivae, including gingival bleeding upon probing. For patients having coexisting gingivitis and periodontitis, read PRECAUTIONS indicated on the insert inside the box.

Store at controlled room temperature 68-77F (20-25C). Protect from freezing.

0.12% Chlorhexidine Gluconate

Antigingivitis


GELATO CHLOROHEXIDINE 
chlorhexidine gluconate  rinse Product Information Product Type HUMAN PRESCRIPTION DRUG NDC Product Code (Source) 68400-500 Route of Administration DENTAL, TOPICAL, ORAL DEA Schedule      Active Ingredient/Active Moiety Ingredient Name Basis of Strength Strength CHLORHEXIDINE GLUCONATE (CHLORHEXIDINE) CHLORHEXIDINE GLUCONATE 56.76 mL  in 473 mL Inactive Ingredients Ingredient Name Strength Water   Glycerin   FD&C BLUE NO. 1   SACCHARIN SODIUM   POLYSORBATE 20   POLOXAMER 407   Product Characteristics Color      Score      Shape Size Flavor MINT Imprint Code Contains          Packaging # NDC Package Description Multilevel Packaging 1 68400-500-16 473 mL In 1 BOTTLE None
Marketing Information Marketing Category Application Number or Monograph Citation Marketing Start Date Marketing End Date unapproved drug other 03/31/2010
Labeler - Deepak Products, inc. (124886743) Establishment Name Address ID/FEI Operations Deepak Products, inc. 124886743 manufacture Revised: 04/2011Deepak Products, inc.
More Gelato Chlorhexidine Rinse resources Gelato Chlorhexidine Rinse Side Effects (in more detail) Gelato Chlorhexidine Rinse Use in Pregnancy & Breastfeeding Gelato Chlorhexidine Rinse Support Group 1 Review for Gelato Chlorhexidine - Add your own review/rating Compare Gelato Chlorhexidine Rinse with other medications Gingivitis Mucositis Periodontitis
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Vet One Chlorhexidine



Dosage Form: FOR ANIMAL USE ONLY
MWI/Vet One 2% Chlorhexidine solution MWI/Vet One 2% Chlorhexidine solution

ACTIVE INGREDIENTS:
2% Chlorhexidine Gluconate.

CAUTION:
Avoid contact with eyes and mucous membranes. This product is not to be used in ears. If contact is made, flush immediately and thoroughly with clean water. For use on horses and dogs.

Product No. 1CHL008
8CHL008-108
Distributed by:
MWI
Meridian, ID 83680
(888) 694-8381
MWI/Vet One 2% Chlorhexidine solution

PRODUCT DESCRIPION:
A topical aqueous cleaning solution for use on horses and dogs for application to superficial cuts, abrasions or insect stings.

DILUTE:
1 ounce (2 tablespoons) of Chlorhexidine Solution per gallon of clean water.
DIRECTIONS FOR USE:
Rinse skin area to be treated with Chlorhexidine Solution. Wipe away excess and pat dry with sterilized gauze or sponge.
MWI/Vet One 2% Chlorhexidine solution


Vet One Chlorhexidine 
chlorhexidine gluconate  solution Product Information Product Type OTC ANIMAL DRUG NDC Product Code (Source) 13985-017 Route of Administration TOPICAL DEA Schedule      Active Ingredient/Active Moiety Ingredient Name Basis of Strength Strength Chlorhexidine Gluconate (CHLORHEXIDINE) Chlorhexidine Gluconate 2 g  in 0.1 L Inactive Ingredients Ingredient Name Strength No Inactive Ingredients Found Product Characteristics Color      Score      Shape Size Flavor Imprint Code Contains          Packaging # NDC Package Description Multilevel Packaging 1 13985-017-80 3.785 L In 1 JUG None
Marketing Information Marketing Category Application Number or Monograph Citation Marketing Start Date Marketing End Date unapproved drug other 01/01/2010
Labeler - MWI VETERINARY SUPPLY CO (019926120) Revised: 01/2010MWI VETERINARY SUPPLY CO

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Hex-Plus


Generic Name: chlorhexidine gluconate liquid
Dosage Form: FOR ANIMAL USE ONLY
Hex-Plus

USE DIRECTIONS:
Use at full strength, do not dilute.


POST-MILKING:
Dip entire teat in Hex-Plus.  Allow to air dry.
If solution in cup becomes visibly dirty.  Then
replenish with Hex-Plus at full strength.  Do
not return unused product to original container.
PROTECT FROM FREEZING
IF FROZEN: SHAKE VIGOROUSLY
AFTER THAWING

WARNING:  CONTAINS CHLORHEXIDINE
GLUCONATE.

Not for human use.
Avoid contamination of food.  Avoid contact
with eyes.  Not for internal use.


OBSERVE LABEL DIRECTIONS

KEEP OUT OF REACH OF CHILDREN!

FIRST AID:
INTERNAL:  If swallowed, do not induce vomiting.
Drink large quantities of water.  See physician immediately.

EYES:  Flush eyes with clear water for 15 minutes.If irritated, obtain medical guidance.
GET MEDICAL ATTENTION IMMEDIATELY.

Hex-Plus

SANITIZING CHLORHEXIDINE TEAT DIP
FORMULATED WITH EMOLLIENTS AND
DERMAL CONDITIONERS


This product, when properly used, is effective as an aid
in reducing the spread of organisms which may cause
mastitis.
Active Ingredient..........1.0% Chlorhexidine Gluconate
Contains 10% Emollient
Lot#:______________________

Exp. Date:___________________

Next Content:________________


Manufactured For:
Tetradyne LLC
PO Box 17003
Reno, NV 89511


Hex-Plus 
teat dip  liquid Product Information Product Type OTC ANIMAL DRUG NDC Product Code (Source) 66399-742 Route of Administration TOPICAL DEA Schedule      Active Ingredient/Active Moiety Ingredient Name Basis of Strength Strength CHLORHEXIDINE GLUCONATE (CHLORHEXIDINE) CHLORHEXIDINE GLUCONATE 1.0 L  in 100 L Inactive Ingredients Ingredient Name Strength GLYCERIN 10 L  in 100 L Product Characteristics Color      Score      Shape Size Flavor Imprint Code Contains          Packaging # NDC Package Description Multilevel Packaging 1 66399-742-01 3.78 L In 1 JUG None 2 66399-742-02 18.9 L In 1 PAIL None 3 66399-742-03 56.7 L In 1 DRUM None 4 66399-742-04 113.4 L In 1 DRUM None 5 66399-742-05 207.9 L In 1 DRUM None 6 66399-742-06 945 L In 1 CONTAINER, FLEXIBLE INTERMEDIATE BULK None 7 66399-742-07 1039.5 L In 1 CONTAINER, FLEXIBLE INTERMEDIATE BULK None
Marketing Information Marketing Category Application Number or Monograph Citation Marketing Start Date Marketing End Date unapproved drug other 09/10/2001
Labeler - Tetradyne LLC (130969293) Revised: 11/2010Tetradyne LLC

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Hex-Tra


Generic Name: chlorhexidine gluconate liquid
Dosage Form: FOR ANIMAL USE ONLY
Hex-Tra

USE DIRECTIONS:
Use at full strength, do not dilute.


POST-MILKING:
Dip entire teat in Hex-Tra.  Allow to air dry.
If solution in cup becomes visibly dirty.  Then
replenish with Hex-Tra at full strength.  Do
not return unused product to original container.
PROTECT FROM FREEZING
IF FROZEN: SHAKE VIGOROUSLY
AFTER THAWING

WARNING:  CONTAINS CHLORHEXIDINE
GLUCONATE.

Not for human use.
Avoid contamination of food.  Avoid contact
with eyes.  Not for internal use.


OBSERVE LABEL DIRECTIONS

KEEP OUT OF REACH OF CHILDREN!

FIRST AID:
INTERNAL:  If swallowed, do not induce vomiting.
Drink large quantities of water.  See physician immediately.

EYES:  Flush eyes with clear water for 15 minutes.If irritated, obtain medical guidance.
GET MEDICAL ATTENTION IMMEDIATELY.

Hex-Tra

SANITIZING CHLORHEXIDINE TEAT DIP
FORMULATED WITH EMOLLIENTS AND
DERMAL CONDITIONERS


This product, when properly used, is effective as an aid
in reducing the spread of organisms which may cause
mastitis.
Active Ingredient..........0.50% Chlorhexidine Gluconate
Contains an Emollient System
Lot#:______________________

Exp. Date:___________________

Next Content:________________


Manufactured For:
Tetradyne LLC
PO Box 17003
Reno, NV 89511


Hex-Tra 
teat dip  liquid Product Information Product Type OTC ANIMAL DRUG NDC Product Code (Source) 66399-083 Route of Administration TOPICAL DEA Schedule      Active Ingredient/Active Moiety Ingredient Name Basis of Strength Strength CHLORHEXIDINE GLUCONATE (CHLORHEXIDINE) CHLORHEXIDINE GLUCONATE 0.50 L  in 100 L Inactive Ingredients Ingredient Name Strength GLYCERIN 5.0 L  in 100 L Product Characteristics Color      Score      Shape Size Flavor Imprint Code Contains          Packaging # NDC Package Description Multilevel Packaging 1 66399-083-01 3.78 L In 1 JUG None 2 66399-083-02 18.9 L In 1 PAIL None 3 66399-083-03 56.7 L In 1 DRUM None 4 66399-083-04 113.4 L In 1 DRUM None 5 66399-083-05 207.9 L In 1 DRUM None 6 66399-083-06 945 L In 1 CONTAINER, FLEXIBLE INTERMEDIATE BULK None 7 66399-083-07 1039.5 L In 1 CONTAINER, FLEXIBLE INTERMEDIATE BULK None
Marketing Information Marketing Category Application Number or Monograph Citation Marketing Start Date Marketing End Date unapproved drug other 09/10/2001
Labeler - Tetradyne LLC (130969293) Revised: 11/2010Tetradyne LLC

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Quinidine Gluconate


Class: Class Ia Antiarrhythmics
Note: This monograph also contains information on Quinidine Sulfate
VA Class: CV300
CAS Number: 7054-25-3

Mortality

In many antiarrhythmic drug trials for non-life-threatening arrhythmias, active antiarrhythmic drug therapy was associated with increased mortality.163 167 168 169 170

Risk associated with antiarrhythmic drug therapy probably is greatest in patients with structural heart disease.163 167 168 169 170

A meta-analysis of data from several randomized, controlled studies in patients with atrial flutter and fibrillation indicates that quinidine therapy may be associated with a mortality rate >3 times higher than that associated with placebo.163 167 168 169 170

A meta-analysis in patients with various non-life-threatening ventricular arrhythmias showed mortality associated with quinidine was consistently greater than that associated with various other antiarrhythmic agents (i.e., flecainide, mexiletine, propafenone, tocainide).163 167 168 169 170

Introduction

Antiarrhythmic agent (class IA); antimalarial.119 161 163 167 168 169 170

Uses for Quinidine Gluconate

Comparably effective to procainamide for atrial or ventricular arrhythmias; choice based on pharmacokinetics and adverse effect profile.b

Supraventricular Tachyarrhythmias

Used principally for prophylactic therapy to maintain normal sinus rhythm after conversion of atrial fibrillation and/or flutter by other means.b

Abnormal ventricular rate and CHF should first be controlled by administration of digoxin.b Electrical cardioversion usually is considered the treatment of choice for conversion of atrial fibrillation or flutter.b

Prevention of recurrence of atrial fibrillation or flutter is controversial because mortality may increase despite recurrence suppression.b

May maintain normal sinus rhythm for long periods in recent onset of atrial fibrillation or flutter without CHF, atrial enlargement, or left ventricular hypertrophy, but long-standing atrial fibrillation is likely to recur even with quinidine maintenance therapy.b

Generally, quinidine should not be used prophylactically for atrial fibrillation if the ventricular rate is adequately controlled by digoxin and the patient is asymptomatic.b

Treatment of paroxysmal atrial tachycardia or paroxysmal AV junctional rhythm.b

Atrial Premature Complexes

Treatment of atrial premature complexes; however, these arrhythmias usually are treated with digoxin.b

Ventricular Premature Complexes (VPCs)

Treatment of VPCs; however, parenteral lidocaine is considered the drug of choice because quinidine can decrease myocardial contractility.b

Like other antiarrhythmic drugs, not shown to decrease mortality rate in VPCs associated with AMI.b

Avoid in treatment of asymptomatic VPCs.b

Not for treatment of cardiac glycoside-induced ventricular arrhythmias.b

VT

Treatment of paroxysmal VT that is not associated with complete heart block; however, treatment with cardioversion or lidocaine usually is preferred.b

Suppression and prevention of recurrent ventricular arrhythmias (e.g., sustained VT) that in the judgment of the clinician are life-threatening.b

Because of arrhythmogenic potential and the lack of evidence for improved survival for class I antiarrhythmic agents,146 147 not recommended for less severe VTs; avoid treatment in asymptomatic VPCs.b

Malaria

Treatment of severe, life-threatening malaria caused by Plasmodium falciparum.101 102 104 105 119 122 124 126 142 153 158 162 Drug of choice for initial treatment of severe malaria.101 126 142 153 154 158 162

Severe malaria usually is caused by P. falciparum and requires initial aggressive treatment with a parenteral antimalarial regimen initiated as soon as possible after diagnosis.158 162 Exchange transfusions can be considered if parasitemia is >10% or patient has cerebral malaria, altered mental status, non-volume-overload pulmonary edema, or renal complications.158 162

For initial treatment of severe malaria in adults or children, CDC recommends a regimen of IV quinidine gluconate in conjunction with doxycycline, tetracycline, or clindamycin (oral or IV as tolerated).158 162 After at least 24 hours and when parasitemia is reduced to <1% and an oral regimen can be tolerated, IV quinidine gluconate can be discontinued and oral quinine sulfate initiated to complete 3 or 7 days of total quinidine and quinine therapy as determined by the geographic origin of the infecting parasite (3 days if malaria acquired in Africa or South America or 7 days if acquired in Southeast Asia).158 162

Because of potentially fatal consequences of delays in initiating treatment of severe malaria, institutional pharmacy services should be aware of the essential role of ready availability of IV quinidine gluconate.142 143 153 158 (See Availability for Use in Treatment of Severe Malaria under Cautions.)

When IV quinidine gluconate is unavailable or cannot be used because of intolerance or contraindications, parasitemia is high or has not responded to quinidine gluconate therapy, and a parenteral regimen is indicated, IV artesunate is available from CDC under an investigational new drug (IND) protocol for the treatment of severe malaria.158 162 171 172 WHO and other clinicians recommend artesunate as a drug of choice for the treatment of severe malaria.101 173

Although oral quinidine sulfate has been used for the treatment of malaria,167 170 including uncomplicated malaria† caused by multidrug-resistant P. falciparum,102 104 108 109 110 112 oral quinine sulfate is not included in CDC recommendations for treatment of uncomplicated or severe P. falciparum malaria.158 162

Assistance with diagnosis or treatment of malaria and assistance obtaining IV quinidine gluconate or IV artesunate for treatment of severe malaria is available by contacting the CDC Malaria Hotline at 770-488-7788 from 8:00 a.m. to 4:30 p.m. Eastern Standard Time or CDC Emergency Operation Center at 770-488-7100 after hours, on weekends, and holidays.158 162 171 172

Quinidine Gluconate Dosage and Administration General Arrhythmias

Initiate quinidine or adjust quinidine dosage in a setting where facilities and personnel for patient monitoring and resuscitation are continuously available, especially if used in patients with known structural heart disease or other risk factors for toxicity.163 167 168 169 170

ECG monitoring of cardiac function and determination of plasma concentrations are recommended, especially when given IV or when >2 g is administered orally daily, and in patients with an increased risk of adverse reactions to quinidine (e.g., severe heart disease, hypotension, hepatic or renal disease).b

Use for conversion of atrial fibrillation/flutter only after alternative measures (e.g., use of other drugs to control ventricular rate) have been inadequate.163 167 168 169 170 Discontinue quinidine if sinus rhythm is not restored within a reasonable amount of time.119 163 167 168 169 170

Discontinue quinidine and consider other means of conversion if QRS complex widens to 130% of its pretreatment duration, QTc interval widens to 130% of its pretreatment duration and is >500 milliseconds, P waves disappear, or patient develops clinically important tachycardia, symptomatic bradycardia, or hypotension.119 163 167 168 169 170

Malaria

Initiate IV quinidine gluconate regimen as soon as possible after severe P. falciparum malaria is diagnosed.158 162 CDC recommends the regimen be initiated in patients with strong clinical evidence of severe malaria, even if initial blood smears do not demonstrate parasitemia or indicate P. vivax, P. ovale, or P. malariae infection.158

CDC and others recommend the IV quinidine gluconate regimen be administered in an intensive care facility with close monitoring.101 111 122 123 124 125 126 141 153 158

Monitor BP, plasma quinidine concentrations, and ECG closely and monitor blood glucose periodically in patients receiving quinidine for treatment of malaria; adjust dosage accordingly.101 102 104 111 141 158 162

Because most deaths from severe malaria occur within the first 24–48 hours of illness, an initial loading dose is used to attain therapeutic plasma concentrations rapidly during this critical period of elevated parasitemia.158 A loading dose should not be used if patient received >40 mg/kg of quinine in the previous 48 hours or received mefloquine in the previous 12 hours.158

Calculate loading dose and infusion rate carefully to prevent acute cardiac events.153 Consider that the risk of serious ventricular arrhythmias associated with quinidine is increased by bradycardia, hypokalemia, hypomagnesemia, and concomitant use of drugs that can prolong QT interval (e.g., halofantrine [an antimalarial drug not commercially available in the US], mefloquine, quinine).101 153 158

CDC recommends consultation with a cardiologist and a clinician with experience in treating malaria.153 158 162 A cardiologist may be helpful if attempting to resume IV infusion of quinidine gluconate in patients who develop prolongation of QT interval or hypotension during treatment.153

Administration

Administer quinidine sulfate orally.163 167 Administer quinidine gluconate orally168 169 or by IV infusion.119

IM administration of quinidine gluconate is not recommended because absorption may vary depending on the patient’s peripheral perfusion.119

Oral Administration

Administer quinidine sulfate orally as conventional167 170 or extended-release tablets.163

Administer quinidine gluconate orally as extended-release tablets.168 169

May be administered with food or antacids to decrease adverse GI effects.b Avoid grapefruit juice.156 163 168 169 (See Specific Drugs and Foods under Interactions.)

To determine possible idiosyncrasy to quinidine, administer a test dose of 200 mg of quinidine sulfate orally several hours before initiating full dosage.b For children, the test dose for idiosyncrasy is 2 mg/kg (up to 200 mg) of quinidine sulfate orally.164 b

Extended-release Tablets

Used principally for maintenance therapy in the management of arrhythmias.b

Quinidine gluconate extended-release tablets may be broken in half in order to titrate dosage; however, do not chew or crush.168 169

IV Administration

Arrhythmias: Administer by IV infusion.119

Malaria: Administer by continuous or intermittent IV infusion.101 102 104 111 119 122 123 124 125 158 162

Dilution

Arrhythmias: Dilute contents of multiple-dose vial containing 800 mg of quinidine gluconate (10 mL of 80-mg/mL injection) in 40 mL of 5% dextrose injection to provide solution containing 16 mg/mL.119

Malaria (continuous IV infusion regimen): Dilute loading dose of 6.25 mg/kg of quinidine (10 mg/kg of quinidine gluconate)101 119 141 153 158 in approximately 5 mL/kg of 0.9% sodium chloride injection.119

Malaria (intermittent IV infusion regimen): Dilute loading dose of 15 mg/kg of quinidine (24 mg/kg of quinidine gluconate)119 153 158 in 250 mL of 0.9% sodium chloride injection.119

Rate of Administration

Minimize length of IV tubing because of quinidine adsorption to PVC tubing.119 (See Compatibility under Stability.)

Overly rapid IV administration can cause potentially severe cardiovascular effects.119 (See IV Administration under Cautions.)

Arrhythmias: Up to 0.25 mg/kg per minute (i.e., about 1 mL/kg per hour of 16-mg/mL dilution).119

Malaria (continuous IV infusion regimen): Give loading dose of 6.25 mg/kg of quinidine (10 mg/kg of quinidine gluconate) by IV infusion over 1–2 hours, followed by continuous IV infusions given at a rate of 12.5 mcg/kg of quinidine per minute (20 mcg/kg of quinidine gluconate per minute) for at least 24 hours.101 119 153 158 Administer infusion at a rate that maintains a plasma quinidine concentration of 3–8 mcg/mL.158 Decrease infusion rate or interrupt flow if corrected QT interval is >0.6 seconds, corrected QT interval exceeds baseline by >25%, QRS widening is >50% of baseline, or clinically important hypotension unresponsive to fluid expansion develops.111 124 128 158

Malaria (intermittent IV infusion regimen): Give loading dose of 15 mg/kg of quinidine (24 mg/kg of quinidine gluconate) by IV infusion over 4 hours, followed 4 hours later (i.e., 8 hours after the beginning of the loading-dose infusion) by maintenance doses of 7.5 mg/kg of quinidine (12 mg/kg of quinidine gluconate) given by IV infusion over 4 hours at 8-hour intervals.119 153 158 Administer infusion at a rate that maintains a plasma quinidine concentration of 3–8 mcg/mL.158 Decrease infusion rate or interrupt flow if corrected QT interval is >0.6 seconds, corrected QT interval exceeds baseline by >25%, QRS widening exceeds baseline by >50%, or clinically important hypotension unresponsive to fluid expansion develops.158

Dosage

Available as quinidine sulfate163 167 170 and quinidine gluconate.119 168 169 Dosage for treatment of arrhythmias usually expressed in terms of the salt;119 163 167 168 169 170 dosage for treatment of malaria expressed in terms of the base or salt.119 158 162

On a molar basis, approximately 267 mg of quinidine gluconate is equivalent to 200 mg of quinidine sulfate.b

Each 100 mg of quinidine gluconate contains 62.5 mg of quinidine.119

Pediatric Patients Quinidine Sulfate Arrhythmias† Oral

15–60 mg/kg of quinidine sulfate daily given in divided doses every 6 hours has been recommended by some clinicians.164 165 Others recommend 30 mg/kg daily or 900 mg/m2 daily, given in 5 divided doses.b

Quinidine Gluconate Arrhythmias† Oral

20–60 mg/kg of quinidine gluconate daily given in divided doses every 8 hours has been recommended by some clinicians.165

IV

30 mg/kg daily or 900 mg/m2 daily of quinidine gluconate, given in 5 divided doses, is recommended by some clinicians.b

Severe Malaria IV

Continuous IV infusion regimen: Initial loading dose of 6.25 mg/kg of quinidine (10 mg/kg of quinidine gluconate) given by IV infusion over 1–2 hours,101 119 158 162 followed by a maintenance infusion of 12.5 mcg/kg of quinidine per minute (20 mcg/kg of quinidine gluconate per minute) continued for ?24 hours and until parasitemia is reduced to <1% and oral quinine sulfate can be substituted.101 111 119 122 123 124 125 141 158 162 Some clinicians state initial loading dose should not exceed 375 mg of quinidine (600 mg of quinidine gluconate).101

Intermittent IV infusion regimen: Initial loading dose of 15 mg/kg of quinidine (24 mg/kg of quinidine gluconate) given by IV infusion over 4 hours, followed 4 hours later (i.e., 8 hours after the beginning of the loading-dose infusion) by maintenance doses of 7.5 mg/kg of quinidine (12 mg/kg of quinidine gluconate) given by IV infusion over 4 hours at 8-hour intervals until 3 maintenance doses have been administered and parasitemia is reduced to <1% and oral quinine sulfate can be substituted.119 153 158 162

After ?24 hours of quinidine gluconate and when clinically indicated, switch to oral quinine sulfate therapy to complete a total of 3 or 7 days of total quinidine and quinine therapy as determined by the geographic origin of the infecting parasite (3 days if malaria was acquired in Africa or South America or 7 days if acquired in Southeast Asia).122 123 141 158 162

The IV quinidine gluconate regimen followed by oral quinine sulfate is used in conjunction with a 7-day regimen of doxycycline, tetracycline, or clindamycin (given IV or orally as tolerated).158

Adults Quinidine Sulfate Arrhythmias Oral

Conversion of atrial fibrillation/flutter (conventional tablets): Manufacturers recommend 400 mg of quinidine sulfate (332 mg of quinidine) every 6 hours initially; dose may be cautiously increased if conversion is not attained after 4 or 5 doses.167 170

Conversion of atrial fibrillation/flutter (extended-release tablets): Manufacturer recommends 300 mg of quinidine sulfate (249 mg of quinidine) every 8–12 hours initially; dose may be cautiously increased if conversion not attained, quinidine serum concentrations are within the therapeutic range, and the drug is well tolerated.163

If successful conversion of atrial fibrillation does not occur when quinidine serum concentrations are in the therapeutic range, further dosage increases generally are unsuccessful and increase the possibility of toxicity.b

Reduction in frequency of relapse into atrial fibrillation/flutter (conventional tablets): Manufacturers recommend 200 mg of quinidine sulfate (166 mg of quinidine) every 6 hours initially.167 170 Dose may be cautiously increased if well tolerated, serum quinidine concentrations are within therapeutic range, and average time between arrhythmic episodes has not been satisfactorily increased.167 170 Use such prophylaxis only if alternative measures have been inadequate and if potential benefits outweigh risks;167 170 consider mortality risk.167 170

Reduction in frequency of relapse into atrial fibrillation/flutter (extended-release tablets): Manufacturer recommends 300 mg of quinidine sulfate (249 mg of quinidine) every 8–12 hours initially.163 Dose may be cautiously increased if well tolerated, serum quinidine concentrations are within therapeutic range, and average time between arrhythmic episodes has not been satisfactorily increased.163 Use such prophylaxis only if alternative measures have been inadequate and if potential benefits outweigh risks;163 consider mortality risk.163

Manufacturers state that dosage regimens for suppression of life-threatening ventricular arrhythmias have not been adequately studied, but regimens similar to those used in the management of atrial fibrillation/flutter have been described.163 167 170 Whenever possible, such therapy should be guided by results of programmed electrical stimulation and/or Holter monitoring with exercise.163 167 170

Malaria Oral

300–600 mg or 10 mg/kg of quinidine sulfate every 8 hours for 5–7 days has been used for the treatment of uncomplicated P. falciparum malaria.102 103 108 109 110

Not included in CDC recommendations for treatment of uncomplicated or severe malaria.158 162 (See Malaria under Uses.)

Quinidine Gluconate Arrhythmias Oral

Conversion of atrial fibrillation/flutter (extended-release tablets): Manufacturers recommend 648 mg of quinidine gluconate (403 mg of quinidine) every 8 hours initially; dose may be cautiously increased if conversion is not attained after 3 or 4 doses.168 169 Alternatively, manufacturers state that a regimen of 324 mg of quinidine gluconate (202 mg of quinidine) may be given every 8 hours for 2 days, then 648 mg of quinidine gluconate (403 mg of quinidine) every 12 hours for 2 days, and then 648 mg of quinidine gluconate (403 mg of quinidine) every 8 hours for up to 4 days.168 169 If the 648-mg dose is not tolerated, the lower dosage can be continued for the last 4 days.168 169

Reduction in frequency of relapse into atrial fibrillation/flutter (extended-release tablets): Manufacturers recommend 324 mg of quinidine gluconate (202 mg of quinidine) every 8 or 12 hours initially.168 169 Dose may be cautiously increased if well tolerated, serum quinidine concentrations are within therapeutic range, and average time between arrhythmic episodes has not been satisfactorily increased.168 169 Use such prophylaxis only if alternative measures have been inadequate and if potential benefits outweigh risks;168 169 consider mortality risk.168 169

Manufacturers state that dosage regimens for suppression of life-threatening ventricular arrhythmias have not been adequately studied, but regimens similar to those used in the management of atrial fibrillation/flutter have been described.168 169 Whenever possible, such therapy should be guided by results of programmed electrical stimulation and/or Holter monitoring with exercise.168 169

IV

Treatment of symptomatic atrial fibrillation/flutter: Initially, up to 0.25 mg/kg of quinidine gluconate per minute (i.e., up to 1 mL/kg per hour) of 16-mg/mL dilution.119 Discontinue IV infusion as soon as sinus rhythm is restored.119

Most arrhythmias responsive to IV quinidine respond to a total IV dosage <5 mg/kg, although 10 mg/kg may be required in some patients.119 If conversion to sinus rhythm has not occurred after infusion of quinidine gluconate 10 mg/kg, discontinue the infusion and consider other means of cardioversion.119

Although dosing regimens for the management of life-threatening ventricular arrhythmias have not been systematically evaluated, regimens similar to that used in the management of atrial fibrillation/flutter have been described.119

Severe Malaria IV

Continuous IV infusion regimen: Initial loading dose of 6.25 mg/kg of quinidine (10 mg/kg of quinidine gluconate) given by IV infusion over 1–2 hours,101 119 141 158 162 followed by a maintenance infusion of 12.5 mcg/kg of quinidine per minute (20 mcg/kg of quinidine gluconate per minute) continued for ?24 hours and until parasitemia is reduced to <1% and oral quinine sulfate can be substituted.101 111 119 122 123 124 125 141 158 162 Some clinicians state initial loading dose should not exceed 375 mg of quinidine (600 mg of quinidine gluconate).101

Intermittent IV infusion regimen: Initial loading dose of 15 mg/kg of quinidine (24 mg/kg of quinidine gluconate) given by IV infusion over 4 hours, followed 4 hours later (i.e., 8 hours after the beginning of the loading-dose infusion) by maintenance doses of 7.5 mg/kg of quinidine (12 mg/kg of quinidine gluconate) given by IV infusion over 4 hours at 8-hour intervals until 3 maintenance doses have been administered and parasitemia is reduced to <1% and oral quinine sulfate can be substituted.119 153 158 162

After ?24 hours of quinidine gluconate and when clinically indicated, switch to oral quinine sulfate therapy to complete a total of 3 or 7 days of total quinidine and quinine therapy as determined by the geographic origin of the infecting parasite (3 days if malaria was acquired in Africa or South America or 7 days if acquired in Southeast Asia).122 123 141 158

The IV quinidine gluconate regimen followed by oral quinine sulfate is used in conjunction with a 7-day regimen of doxycycline, tetracycline, or clindamycin (given IV or orally as tolerated).158 162

Prescribing Limits Pediatric Patients Arrhythmias† Quinidine Gluconate or Quinidine Sulfate Oral

2.4 g of quinidine sulfate or quinidine gluconate daily.165

Severe Malaria Quinidine Gluconate IV

Continuous IV infusion regimen: Maximum initial loading dose of 375 mg of quinidine (600 mg of quinidine gluconate).101

Adults Severe Malaria Quinidine Gluconate IV

Continuous IV infusion regimen: Maximum initial loading dose of 375 mg of quinidine (600 mg of quinidine gluconate).101

Special Populations Hepatic Impairment

Dosage reduction may be necessary to avoid toxicity.119 163 167 168 169 170

Renal Impairment

Dosage reduction may be necessary to avoid toxicity.119 163 167 168 169 170

In patients with severe malaria receiving IV quinidine gluconate, CDC states that initial (including loading) doses do not need to be reduced in those with renal failure.158 If renal failure persists or clinical improvement does not occur in such patients, CDC recommends reducing maintenance IV infusion rate by one-third to one-half on the third day of treatment.158

CHF

Dosage reduction may be necessary to avoid toxicity.119 163 167 168 169 170

Geriatric Patients

Select dosage with caution, usually starting at the low end of the dosage range, and consider age-related decreases in hepatic, renal, and/or cardiac function and concomitant disease and drug therapy.119

Cautions for Quinidine Gluconate Contraindications

Patients with AV junctional or idioventricular pacemaker, including those in complete AV block.119 163 167 168 169 170

History of quinidine- or quinine-associated thrombocytopenic purpura.119 163 167 168 169 170

Myasthenia gravis or other conditions that might be adversely affected by anticholinergic effects.119 163 167 168 169 170

Known hypersensitivity to quinidine.119 163 167 168 169 170

Warnings/Precautions Warnings Mortality

Pooled analysis of data from several randomized, controlled studies in patients with ventricular arrhythmias indicates that mortality rate associated with quinidine therapy is at least as high as that associated with other antiarrhythmic agents (e.g., flecainide, mexiletine, propafenone, tocainide).b

Use quinidine only for life-threatening arrhythmias.145 Avoid use for less severe ventricular arrhythmias and treatment of asymptomatic VPCs.145

Additionally, pooled analysis of data from several randomized, controlled studies in patients with atrial flutter and fibrillation indicates that quinidine therapy may be associated with a mortality rate more than 3 times higher than that associated with placebo;163 167 168 169 170 consider the increased risk of death when initiating quinidine therapy.144

Use with extreme caution, if at all, in patients with incomplete AV nodal block, since complete heart block and asystole may result.b Parenteral administration is especially hazardous in the presence of AV block, in the absence of atrial activity, and in patients with extensive myocardial injury.b

Proarrhythmic Effects

The possibility that potentially serious cardiac arrhythmias, including torsades de pointes, could occur if used concomitantly with other drugs that prolong the QTc interval should be considered and such combined use should be avoided.151

Hypokalemia, hypoxia, and disorders of acid-base balance must be eliminated as potentiating factors in patients who require large doses of antiarrhythmic agents to control ventricular arrhythmias.b

Paradoxical Increase in Ventricular Rate in Atrial Flutter/Fibrillation

Paradoxically, an extremely rapid ventricular rate may occur when used in the treatment of atrial flutter or fibrillation, due to a reduction in the degree of AV nodal block to a 1:1 ratio.b The anticholinergic action on the AV node also may increase the heart rate.b

This tachycardia may be prevented by prior digitalization.b

If cessation of atrial fibrillation or flutter is accompanied by depression of the normal pacemaker, an idioventricular rhythm (including ventricular tachycardia and fibrillation) may result.b

Exacerbated Bradycardia in Sick Sinus Syndrome

Possible marked sinus node depression and bradycardia.b

IV Administration

Overly rapid IV administration may cause peripheral vascular collapse and hypotension.119

Sensitivity Reactions Hypersensitivity Reactions

Idiosyncratic and hypersensitivity reactions to quinidine may occur, and the reaction to a test dose or the first dose of the drug should be observed carefully.b (See Oral Administration under Dosage and Administration.)

Observe for hypersensitivity for the first weeks of therapy.b

Symptoms of cinchonism such as tinnitus, headache, vertigo, fever, dizziness, lightheadedness, tremor, nausea, and disturbed vision may occur in sensitive patients after a single dose.b

Decrease dosage if signs of cinchonism appear.b

General Precautions Cardiovascular Effects

Possible syncope, probably due to ventricular tachycardia or fibrillation in usual doses.b May subside spontaneously, but occasionally are fatal.b If quinidine-induced syncope occurs, discontinue the drug.b Also may cause bradycardia.b

Severe hypotension may occur following IV administration or oral overdosage.b Vascular collapse, respiratory distress, and respiratory arrest may occur.b Reportedly related to the dose and rate of administration of the drug.102 107 119 Rapid IV injection of as little as 200 mg reportedly may cause a decrease in blood pressure of 40–50 mm Hg.119 Norepinephrine or metaraminol may be used if necessary to treat vascular collapse; artificial respiration and other supportive measures may be required.b

While substantial cardiovascular toxicity generally has not occurred, ECG changes, including prolonged QT interval, widened QRS complex, and flattened T waves (without dysrhythmia), have occurred frequently and hypotension and ventricular tachycardia have occurred occasionally in patients receiving IV quinidine gluconate for the treatment of Plasmodium falciparum malaria.102 104 108 124

Use with caution in patients without implanted pacemakers at high risk of complete atrioventricular block (e.g., digitalis intoxication, second-degree atrioventricular block, severe intraventricular conduction defects).163 167 168 169 170

Availability for Use in Treatment of Severe Malaria

Because of potentially fatal consequences of delays in initiating treatment of severe malaria, institutional pharmacy services should be aware of the essential role of ready availability of IV quinidine gluconate.b 142 143 153 158

If IV quinidine gluconate is not readily available for a patient with severe P. falciparum malaria (e.g., in hospitals where the drug is not maintained on formulary or otherwise available), health-care professionals should contact a nearby healthcare facility that stocks the drug.158 If a local source cannot be found, contact the local or regional distributor of the drug.158

If IV quinidine gluconate is unavailable, cannot be used because of intolerance or contraindications, or parasitemia is high or has not responded to quinidine gluconate therapy, IV artesunate is available from the CDC under an IND protocol for treatment of severe malaria.158 162 171 (See Malaria under Uses.)

Specific Populations Pregnancy

Category C.119 163 166 167 168 169 170

Generally considered relatively safe at usual dosages, but may exhibit oxytocic effect (possible abortion) at high dosages.166

Lactation

Distributed into milk.119 163 166 167 168 169 170 Avoid, if possible, in nursing women.119 163 167 168 169 170

Pediatric Use

Safety and efficacy as an antiarrhythmic agent in children not established.119 163 167 168 169 170 Has been used in children with arrhythmias†.165 b

Study and experience in children with malaria suggest that safety and efficacy of IV quinidine gluconate are similar to those in adults.119

Geriatric Use

Safety and efficacy not systematically studied in geriatric patients.119 167 168 169 170 Clinical studies did not include sufficient numbers of patients ?65 years of age to determine whether they respond differently than younger adults;119 other reported clinical experience has not identified differences in responses between geriatric adults and younger patients.119

When used in geriatric patients, select dosage with caution, usually initiating therapy at the low end of dosage range, and consider the greater frequency of decreased hepatic, renal, and/or cardiac function and concomitant disease and drug therapy in this age group.119

Hepatic Impairment

Decreased clearance;119 163 167 168


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HYDREX PINK CHLORHEXIDINE GLUCONATE 0.5% W / V IN 70% V / V DEB.


1. Name Of The Medicinal Product

HYDREX®, PINK CHLORHEXIDINE GLUCONATE 0.5% W/V IN 70% V/V DEB.

2. Qualitative And Quantitative Composition

Chlorhexidine Gluconate Solution 20% BP (Ph Eur) – 2.5% v/v

3. Pharmaceutical Form

Liquid

4. Clinical Particulars 4.1 Therapeutic Indications

This product is for pre-operative skin disinfection prior to minor surgical procedures.

4.2 Posology And Method Of Administration

This product is applied topically.

4.3 Contraindications

i) Do not use in patients who are hypersensitive to Chlorhexidine.

ii) Do not use in contact with eyes, brain, meninges, middle ear or external ear with a perforated tympanic membrane.

iii) Do not inject.

iv) Do not use in body cavities.

v) When use is to be followed by diathermy do not allow pooling of the fluid to occur and ensure that the skin and surrounding drapes are dry.

4.4 Special Warnings And Precautions For Use

i) Precautions:- irritant skin reaction and generated allergic reactions to chlorhexidine have been reported.

ii) Accidental ingestion:- chlorhexidine is poorly absorbed orally. Treat with gastric lavage using milk, egg white, gelatin or mild soap. Employ supportive measures as appropriate.

iii) Accidental intravenous infusion - blood transfusion may be necessary to counteract haemolysis.

4.5 Interaction With Other Medicinal Products And Other Forms Of Interaction

None stated

4.6 Pregnancy And Lactation

None stated

4.7 Effects On Ability To Drive And Use Machines

None stated

4.8 Undesirable Effects

None stated

4.9 Overdose

None stated

5. Pharmacological Properties 5.1 Pharmacodynamic Properties

None stated

5.2 Pharmacokinetic Properties

None stated

5.3 Preclinical Safety Data

None stated

6. Pharmaceutical Particulars 6.1 List Of Excipients

Denatured Ethanol B 96%

Purified Water BP

111959 Carmoisine (E122)

6.2 Incompatibilities

Not applicable

6.3 Shelf Life

2 years

6.4 Special Precautions For Storage

Do not store above 25°C. Store in the original package.

6.5 Nature And Contents Of Container

HDPE containers in the following sizes 50 ml, 200 ml, 500 ml, 600 ml, 1000 ml and 2000 ml.

6.6 Special Precautions For Disposal And Other Handling

Not applicable

7. Marketing Authorisation Holder

Ecolab Ltd, Lotherton Way, Garforth, Leeds, LS25 2JY.

8. Marketing Authorisation Number(S)

PL 04509/0018

9. Date Of First Authorisation/Renewal Of The Authorisation

1 March 2003

10. Date Of Revision Of The Text

August 2006 / November 2008


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HYDREX CLEAR CHLORHEXIDINE GLUCONATE 0.5% W / V IN 70% V / V DEB.


1. Name Of The Medicinal Product

HYDREX®, CLEAR CHLORHEXIDINE GLUCONATE 0.5% W/V IN 70% V/V DEB.

2. Qualitative And Quantitative Composition

Chlorhexidine Gluconate Solution 20% BP (Ph Eur) – 2.5% v/v

3. Pharmaceutical Form

Liquid

4. Clinical Particulars 4.1 Therapeutic Indications

This product is for pre-operative skin disinfection prior to minor surgical procedures

4.2 Posology And Method Of Administration

This product is applied topically.

4.3 Contraindications

i) Do not use in patients who are hypersensitive to chlorhexidine.

ii) Do not use in contact with eyes, brain, meninges, middle ear or external ear with a perforated tympanic membrane.

iii) Do not inject.

iv) Do not use in body cavities.

v) When use is to be followed by diathermy do not allow pooling of the fluid to occur and ensure that the skin and surrounding drapes are dry.

4.4 Special Warnings And Precautions For Use

i) Precautions:- irritant skin reaction and generated allergic reactions to chlorhexidine have been reported.

ii) Accidental ingestion:- chlorhexidine is poorly absorbed orally. Treat with gastric lavage using milk, egg white, gelatin or mild soap. Employ supportive measures as appropriate.

iii) Accidental intravenous infusion - blood transfusion may be necessary to counteract haemolysis.

4.5 Interaction With Other Medicinal Products And Other Forms Of Interaction

None stated

4.6 Pregnancy And Lactation

None stated

4.7 Effects On Ability To Drive And Use Machines

None stated

4.8 Undesirable Effects

None stated

4.9 Overdose

None stated

5. Pharmacological Properties 5.1 Pharmacodynamic Properties

None stated

5.2 Pharmacokinetic Properties

None stated

5.3 Preclinical Safety Data

None stated

6. Pharmaceutical Particulars 6.1 List Of Excipients

Denatured Ethanol B 96%

Purified Water BP

6.2 Incompatibilities

Not applicable

6.3 Shelf Life

3 years

6.4 Special Precautions For Storage

Do not store above 25°C. Store in the original package.

6.5 Nature And Contents Of Container

Hydrex, Clear Chlorhexidine is packaged in HDPE containers in the following sizes 50ml, 200ml, 500ml, 600ml, 1000ml and 2000ml.

6.6 Special Precautions For Disposal And Other Handling

Not applicable

7. Marketing Authorisation Holder

Ecolab Ltd, Lotherton Way, Garforth, Leeds, LS25 2JY.

8. Marketing Authorisation Number(S)

PL 04509/0017

9. Date Of First Authorisation/Renewal Of The Authorisation

1 March 2003

10. Date Of Revision Of The Text

August 2006 / November 2008


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Boots Pharmacy Anaesthetic Throat Spray


Boots Pharmacy Anaesthetic Throat Spray

(Lidocaine Hydrochloride)

Specifically to:

Relieve severe sore throat pain

20 ml e

Read all of this carton for full instructions.

A local anaesthetic spray to provide direct and soothing relief from the pain of severe sore throats.

Before you use this medicine Do not use: If you are allergic to any of the ingredients If you have asthma, or difficulty breathing If you are under 12 years of age Talk to your pharmacist or doctor: If you are receiving any medical treatment If you have a high fever, headache, feel sick or are being sick as well as having a sore throat If you are pregnant or breastfeeding

This spray may cause your tongue to become numb. You must take care when eating or drinking hot foods or drinks.

How to use this medicine

Use at the back of the throat only.

Do not breathe in when you use the spray, or get the spray in your eyes.

To spray: Swing the nozzle through 90° and press.

Before first use or after storing the spray for a long time: Press the spray 3 times away from the face into a sink.

Adults and children of 12 years and over
Three sprays at the back of the throat every 3 hours, if you need to.
Don’t use more than 6 times in any 24 hours.

Do not use for children under 12 years.

Do not use more than the amount recommended above.

If you use too much:

Talk to a doctor straight away. Take your medicine with you.

If symptoms do not go away, talk to your doctor.

Possible side effects

Most people will not have problems, but some may get some.

If you get any of these serious side effects, stop using the spray.

See a doctor at once:

Difficulty in breathing, swelling of the face, neck, tongue or throat (severe allergic reactions)

If you notice any side effect not listed here, please tell your pharmacist or doctor.

Keep all medicines out of the sight and reach of children.

Use by the date on the side of the carton.

Active ingredient

This liquid contains Lidocaine Hydrochloride 2% w/v.

Also contains: purified water, ethanol (30 vol %), sorbitol (E420), sodium citrate, saccharin, quinoline yellow (E104), patent blue V (E131), flavours (peppermint, levomenthol, aniseed).

PL00014/0430

P

Text prepared 10/07

Manufactured for the Marketing Authorisation holder Boots Pharmacy Nottingham NG2 3AA

by

The Boots Company PLC Nottingham NG2 3AA

Contains approximately 150 sprays.

If you need more advice ask your pharmacist.

BTC22021 vE 15/05/08


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Quin-G


Generic Name: quinidine (KWIH nih deen)
Brand Names: Quin-G

What is Quin-G (quinidine)?

Quinidine affects the way that the heart beats.

Quinidine is used to help keep the heart beating normally in people with certain heart rhythm disorders.

Quinidine may also be used for purposes not listed in this medication guide.

What is the most important information I should know about Quin-G (quinidine)? You should not take this medication if you have ever had an allergic reaction to quinidine or quinine (Qualaquin), including easy bruising or unusual bleeding. You should not take quinidine if you have myasthenia gravis or certain heart conditions, especially "AV block" (unless you have a pacemaker).

Before you take quinidine, tell your doctor if you have a slow heart rate, congestive heart failure, a serious heart condition such as "sick sinus syndrome," kidney or liver disease, low levels of potassium or magnesium in your blood, a history of "Long QT syndrome," if you are on a low-salt diet, or if you have ever had an abnormal electrocardiogram or ECG (sometimes called an EKG).

If you need surgery, tell the surgeon ahead of time that you are using quinidine. You may need to stop using the medicine for a short time. Ask your doctor how to adjust your quinidine dose if needed. Do not change your medication dose or schedule without your doctor's advice. Call your doctor at once if you have a serious side effect such as: vomiting and diarrhea, ringing in the ears, hearing loss, severe dizziness, changes in vision, pain behind your eyes, white patches or cloudiness in your eyes, pale or yellowed skin, dark urine, easy bruising or bleeding, wheezing, trouble breathing, or a new or a worsening irregular heartbeat pattern. There are many other drugs that can interact with quinidine. Tell your doctor about all medications you use. This includes prescription, over-the-counter, vitamin, and herbal products. Do not start a new medication without telling your doctor. Keep a list of all your medicines and show it to any healthcare provider who treats you. What should I discuss with my healthcare provider before taking Quin-G (quinidine)? You should not take this medication if you have ever had an allergic reaction to quinidine or quinine (Qualaquin), including easy bruising or unusual bleeding. You should not take quinidine if you have myasthenia gravis or certain heart conditions, especially "AV block" (unless you have a pacemaker).

To make sure you can safely take quinidine, tell your doctor if you have any of these other conditions:

slow heart rate;

congestive heart failure;

a serious heart condition such as "sick sinus syndrome";

kidney disease;

liver disease;

low levels of potassium or magnesium in your blood;

a history of "Long QT syndrome";

if you are on a low-salt diet; or

if you have ever had an abnormal electrocardiogram or ECG (sometimes called an EKG).

FDA pregnancy category C. It is not known whether quinidine will harm an unborn baby. Tell your doctor if you are pregnant or plan to become pregnant while using this medication. Quinidine can pass into breast milk and may harm a nursing baby. Do not use this medication without telling your doctor if you are breast-feeding a baby. How should I take Quin-G (quinidine)?

Take exactly as prescribed by your doctor. Do not take in larger or smaller amounts or for longer than recommended. Follow the directions on your prescription label.

Your doctor may occasionally change your dose to make sure you get the best results.

Do not crush or chew an extended-release tablet. Swallow it whole. You may break the tablet in half if your doctor instructs you to. If you need surgery, tell the surgeon ahead of time that you are using quinidine. You may need to stop using the medicine for a short time. Ask your doctor how to adjust your quinidine dose if needed. Do not change your medication dose or schedule without your doctor's advice.

Use quinidine regularly to get the most benefit. Get your prescription refilled before you run out of medicine completely.

While using quinidine, you may need blood tests at your doctor's office. Visit your doctor regularly.

Store at room temperature away from moisture and heat. What happens if I miss a dose?

Take the missed dose as soon as you remember. Skip the missed dose if it is almost time for your next scheduled dose. Do not take extra medicine to make up the missed dose.

What happens if I overdose? Seek emergency medical attention or call the Poison Help line at 1-800-222-1222.

Overdose symptoms may include vomiting, diarrhea, ringing in your ears or hearing problems, dizziness or spinning sensation, blurred vision, irregular heartbeat, confusion, or feeling like you might pass out.

What should I avoid while taking Quin-G (quinidine)?

Do not change the amount of salt in your diet unless your doctor tells you to.

Grapefruit and grapefruit juice may interact with quinidine and lead to potentially dangerous effects. Discuss the use of grapefruit products with your doctor. Do not increase or decrease the amount of grapefruit products in your diet without first talking to your doctor.

Quin-G (quinidine) side effects Get emergency medical help if you have any of these signs of an allergic reaction: hives; difficult breathing; swelling of your face, lips, tongue, or throat. Call your doctor at once if you have a serious side effect such as:

vomiting and diarrhea;

ringing in the ears, hearing loss, severe dizziness;

feeling like you might pass out;

changes in vision, pain behind your eyes, increased sensitivity of your eyes to light;

white patches on your eyes;

cloudiness in the pupils or iris of your eyes;

a new or a worsening irregular heartbeat pattern;

pale or yellowed skin, dark colored urine, fever, confusion or weakness;

nausea, stomach pain, low fever, loss of appetite, clay-colored stools;

seizure (convulsions);

easy bruising, unusual bleeding (nose, mouth, vagina, or rectum), purple or red pinpoint spots under your skin; or

bronchospasm (wheezing, chest tightness, trouble breathing).

Less serious side effects may include:

mild nausea, vomiting, or diarrhea;

heartburn;

depressed mood;

muscle or joint pain;

headache, dizziness;

mild skin rash;

skin dryness, peeling, or flaking; or

flushing (warmth, redness, or tingly feeling).

This is not a complete list of side effects and others may occur. Call your doctor for medical advice about side effects. You may report side effects to FDA at 1-800-FDA-1088.

What other drugs will affect Quin-G (quinidine)?

Many drugs can interact with quinidine. Below is just a partial list. Tell your doctor if you are using:

cimetidine (Tagamet);

digoxin (Lanoxin);

ketoconazole (Extina, Ketozole, Nizoral, Xolegal);

rifampin (Rifater, Rifadin, Rifamate);

warfarin (Coumadin);

a diuretic (water pill);

glaucoma medication such as acetazolamide (Diamox) or methazolamide (Glauctabs, Neptazane);

heart or blood pressure medication such as diltiazem (Cartia, Cardizem), felodipine (Plendil), nicardipine (Cardene), nimodipine, Nimotop), nifedipine (Nifedical, Procardia), propranolol (Inderal), or verapamil (Calan, Covera, Isoptin, Verelan);

medicines to treat psychiatric disorders, such as haloperidol (Haldol), and others;

narcotic medication such as codeine or hydrocodone (Lortab, Vicodin);

other heart rhythm medications such as amiodarone (Cordarone, Pacerone), mexiletine (Mexitil), disopyramide (Norpace), or procainamide (Procan SR, Procanbid, Pronestyl);

a phenothiazine such as chlorpromazine (Thorazine), promethazine (Phenergan, Promethegan), prochlorperazine (Compazine), and others;

seizure medication such as phenytoin (Dilantin) or phenobarbital (Solfoton);

sodium bicarbonate, potassium citrate (K-Lyte, Urocit-K), sodium citrate and citric acid (Bicitra, Oracit), or sodium citrate and potassium (Citrolith, Polycitra); or

an antidepressant such as amitriptyline (Elavil), doxepin (Sinequan), clomipramine (Anafranil), imipramine (Tofranil), and others.

This list is not complete and there are many other drugs that can interact with quinidine. Tell your doctor about all medications you use. This includes prescription, over-the-counter, vitamin, and herbal products. Do not start a new medication without telling your doctor. Keep a list of all your medicines and show it to any healthcare provider who treats you. More Quin-G resources Quin-G Side Effects (in more detail) Quin-G Use in Pregnancy & Breastfeeding Quin-G Drug Interactions Quin-G Support Group 0 Reviews for Quin-G - Add your own review/rating Cardioquin Advanced Consumer (Micromedex) - Includes Dosage Information Quinidine Professional Patient Advice (Wolters Kluwer) Quinidine Prescribing Information (FDA) Quinidine Gluconate Monograph (AHFS DI) Compare Quin-G with other medications Arrhythmia Malaria Where can I get more information? Your pharmacist can provide more information about quinidine.

See also: Quin-G side effects (in more detail)


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Intermezzo


Generic Name: zolpidem (zole PI dem)
Brand Names: Ambien, Ambien CR, Edluar, Intermezzo, Zolpimist

What is zolpidem?

Zolpidem is a sedative, also called a hypnotic. It affects chemicals in your brain that may become unbalanced and cause sleep problems (insomnia).

Zolpidem is used to treat insomnia. The immediate-release forms of zolpidem are Ambien, Intermezzo, Edluar, and Zolpimist, which are used to help you fall asleep. The extended-release form of zolpidem is Ambien CR, which has a first layer that dissolves quickly to help you fall asleep, and a second layer that dissolves slowly to help you stay asleep.

Ambien, Edluar, and Zolpimist are used to help you fall asleep when you first go to bed. Intermezzo, is used to help you fall back to sleep if you wake up in the middle of the night and then have trouble sleeping.

Your doctor will determine which form of zolpidem is best for you.

Zolpidem may also be used for purposes not listed in this medication guide.

What is the most important information I should know about zolpidem? Zolpidem may cause a severe allergic reaction. Stop taking zolpidem and get emergency medical help if you have any of these signs of an allergic reaction: hives; difficulty breathing; swelling of your face, lips, tongue, or throat. Some people using this medicine have engaged in activity such as driving, eating, or making phone calls and later having no memory of the activity. If this happens to you, stop taking zolpidem and talk with your doctor about another treatment for your sleep disorder. Zolpidem may impair your thinking or reactions. You may still feel sleepy the morning after taking the medication. Wait at least 4 hours or until you are fully awake before you drive, operate machinery, pilot an airplane, or do anything that requires you to be awake and alert. Do not take this medicine if you have consumed alcohol during the day or just before bed. Zolpidem may be habit-forming and should be used only by the person it was prescribed for. Keep the medication in a secure place where others cannot get to it.

It is dangerous to try and purchase zolpidem on the Internet or from vendors outside of the United States. Medications distributed from Internet sales may contain dangerous ingredients, or may not be distributed by a licensed pharmacy. Samples of zolpidem purchased on the Internet have been found to contain haloperidol (Haldol), a potent antipsychotic drug with dangerous side effects. For more information, contact the U.S. Food and Drug Administration (FDA) or visit www.fda.gov/buyonlineguide.

What should I discuss with my healthcare provider before taking zolpidem? Some people using this medicine have engaged in activity such as driving, eating, or making phone calls and later having no memory of the activity. If this happens to you, stop taking zolpidem and talk with your doctor about another treatment for your sleep disorder. You should not use this medication if you are allergic to zolpidem. Zolpidem tablets may contain lactose. Use caution if you are sensitive to lactose.

To make sure you can safely take zolpidem, tell your doctor if you have any of these other conditions:

kidney disease; liver disease;

lung disease such as asthma, bronchitis, emphysema, or chronic obstructive pulmonary disease (COPD);

sleep apnea (breathing stops during sleep);

myasthenia gravis;

a history of depression, mental illness, or suicidal thoughts; or

a history of drug or alcohol addiction.

Zolpidem may be habit forming and should be used only by the person it was prescribed for. Never share zolpidem with another person, especially someone with a history of drug abuse or addiction. Keep the medication in a place where others cannot get to it. FDA pregnancy category C. It is not known whether zolpidem will harm an unborn baby. Tell your doctor if you are pregnant or plan to become pregnant while using this medication. Zolpidem can pass into breast milk and may harm a nursing baby. Do not use this medication without telling your doctor if you are breast-feeding a baby. The sedative effects of zolpidem may be stronger in older adults. Do not give this medicine to anyone younger than 18 years of age.

It is dangerous to try and purchase zolpidem on the Internet or from vendors outside of the United States. Medications distributed from Internet sales may contain dangerous ingredients, or may not be distributed by a licensed pharmacy. Samples of zolpidem purchased on the Internet have been found to contain haloperidol (Haldol), a potent antipsychotic drug with dangerous side effects. For more information, contact the U.S. Food and Drug Administration (FDA) or visit www.fda.gov/buyonlineguide.

How should I take zolpidem?

Take exactly as prescribed by your doctor. Do not take in larger or smaller amounts or for longer than recommended. Follow the directions on your prescription label.

Zolpidem comes with patient instructions for safe and effective use. Follow these directions carefully. Ask your doctor or pharmacist if you have any questions.

Never take Ambien, Edluar, or Zolpimist if you do not have a full 7 to 8 hours to sleep before being active again.

Do not take Intermezzo for middle-of-the-night insomnia unless you have 4 hours of sleep time left before being active.

Zolpidem is for short-term use only. Tell your doctor if your insomnia symptoms do not improve, or if they get worse after using this medication for 7 to 10 nights in a row. Do not take zolpidem for longer than 4 or 5 weeks without your doctor's advice. Do not stop using zolpidem suddenly after long-term use, or you could have unpleasant withdrawal symptoms. Ask your doctor how to avoid withdrawal symptoms when you stop using the medicine.

Insomnia symptoms may also return after you stop taking zolpidem. These symptoms may seem to be even worse than before you started taking the medication. Call your doctor if you still have worsened insomnia after the first few nights without taking zolpidem.

Do not crush, chew, or break an Ambien CR tablet. Swallow the pill whole. Breaking the pill may cause too much of the drug to be released at one time.

Do not swallow the Edluar or Intermezzo tablet whole. Place the tablet under your tongue and allow it to dissolve in your mouth without water.

Spray Zolpimist directly into your mouth over your tongue. Prime the spray before the first use by pumping 5 test sprays into the air, away from your face. Prime the spray with 1 test spray if it has not been used for longer than 14 days.

Store at room temperature away from moisture and heat. Do not freeze. Keep the Zolpimist bottle upright when not in use. What happens if I miss a dose?

Since zolpidem is taken only at bedtime, you will not be on a frequent dosing schedule.

What happens if I overdose? Seek emergency medical attention or call the Poison Help line at 1-800-222-1222. An overdose of zolpidem can be fatal when it is taken together with other medications that can cause drowsiness.

Overdose symptoms may include sleepiness, confusion, shallow breathing, feeling light-headed, fainting, or coma.

What should I avoid while taking zolpidem? Zolpidem may impair your thinking or reactions. You may still feel sleepy the morning after taking the medication. Wait at least 4 hours or until you are fully awake before you drive, operate machinery, pilot an airplane, or do anything that requires you to be awake and alert.

Avoid taking zolpidem during travel, such as to sleep on an airplane. You may be awakened before the effects of the medication have worn off. Amnesia (forgetfulness) is more common if you do not get a full 7 to 8 hours of sleep after taking zolpidem.

Do not take this medicine if you have consumed alcohol during the day or just before bed. Zolpidem side effects Zolpidem may cause a severe allergic reaction. Stop taking zolpidem and get emergency medical help if you have any of these signs of an allergic reaction: hives; difficulty breathing; swelling of your face, lips, tongue, or throat. Report any new or worsening symptoms to your doctor, such as: depression, anxiety, aggression, agitation, confusion, unusual thoughts, hallucinations, memory problems, changes in personality, risk-taking behavior, decreased inhibitions, no fear of danger, or thoughts of suicide or hurting yourself. Stop using zolpidem and call your doctor at once if you have a serious side effects:

chest pain, fast or irregular heartbeat, feeling short of breath;

trouble breathing or swallowing; or

feeling like you might pass out.

Less serious side effects may include:

daytime drowsiness, dizziness, weakness, feeling "drugged" or light-headed;

tired feeling, loss of coordination;

dry mouth, nose or throat irritation;

nausea, constipation, diarrhea, upset stomach;

stuffy nose, sore throat; or

headache, muscle pain.

This is not a complete list of side effects and others may occur. Call your doctor for medical advice about side effects. You may report side effects to FDA at 1-800-FDA-1088.

What other drugs will affect zolpidem? You may need a lower dose of zolpidem if you take other medicines that make you sleepy (such as cold medicine, pain medication, muscle relaxants, and medicine for depression or anxiety). Tell your doctor if you are currently taking any of these medications.

Tell your doctor about all other medicines you use, especially:

chlorpromazine (Thorazine);

itraconazole (Sporanox), ketoconazole (Nizoral);

rifampin (Rifadin, Rimactane, Rifater); or

antidepressants such as imipramine (Tofranil), or sertraline (Zoloft).

This list is not complete and other drugs may interact with zolpidem. Tell your doctor about all medications you use. This includes prescription, over-the-counter, vitamin, and herbal products. Do not start a new medication without telling your doctor.

More Intermezzo resources Intermezzo Side Effects (in more detail) Intermezzo Use in Pregnancy & Breastfeeding Intermezzo Drug Interactions Intermezzo Support Group 0 Reviews for Intermezzo - Add your own review/rating Intermezzo Consumer Overview Zolpidem Prescribing Information (FDA) Ambien Advanced Consumer (Micromedex) - Includes Dosage Information Ambien Consumer Overview Ambien Monograph (AHFS DI) Ambien MedFacts Consumer Leaflet (Wolters Kluwer) Ambien Prescribing Information (FDA) Ambien CR Extended-Release Tablets MedFacts Consumer Leaflet (Wolters Kluwer) Ambien CR Prescribing Information (FDA) Edluar Prescribing Information (FDA) Edluar MedFacts Consumer Leaflet (Wolters Kluwer) Edluar Consumer Overview ZolpiMist Consumer Overview Zolpimist Prescribing Information (FDA) Zolpimist Oral Spray MedFacts Consumer Leaflet (Wolters Kluwer) Compare Intermezzo with other medications Insomnia Where can I get more information? Your pharmacist can provide more information about zolpidem.

See also: Intermezzo side effects (in more detail)


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Antituberculosis agents


Antituberculosis agents are drugs used to treat tuberculosis, an infectious disease caused by Mycobacterium tuberculosis. This infection mainly affects the lungs but can also affect many other organ systems. Many classes of drugs, with different mechanism of action have activity against Mycobacterium tuberculosis.

Tuberculosis chemotherapy involves giving two to four drugs simultaneously. These drugs work differently so they target the organism in different ways and using a few types of drugs prevents drug resistant strains of Mycobacterium from evolving.

See also aminosalicylates antituberculosis combinations miscellaneous antituberculosis agents nicotinic acid derivatives rifamycin derivatives streptomyces derivatives Drug List:
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zolpidem


Generic Name: zolpidem (zole PI dem)
Brand Names: Ambien, Ambien CR, Edluar, Intermezzo, Zolpimist

What is zolpidem?

Zolpidem is a sedative, also called a hypnotic. It affects chemicals in your brain that may become unbalanced and cause sleep problems (insomnia).

Zolpidem is used to treat insomnia. The immediate-release forms of zolpidem are Ambien, Intermezzo, Edluar, and Zolpimist, which are used to help you fall asleep. The extended-release form of zolpidem is Ambien CR, which has a first layer that dissolves quickly to help you fall asleep, and a second layer that dissolves slowly to help you stay asleep.

Ambien, Edluar, and Zolpimist are used to help you fall asleep when you first go to bed. Intermezzo, is used to help you fall back to sleep if you wake up in the middle of the night and then have trouble sleeping.

Your doctor will determine which form of zolpidem is best for you.

Zolpidem may also be used for purposes not listed in this medication guide.

What is the most important information I should know about zolpidem? Zolpidem may cause a severe allergic reaction. Stop taking zolpidem and get emergency medical help if you have any of these signs of an allergic reaction: hives; difficulty breathing; swelling of your face, lips, tongue, or throat. Some people using this medicine have engaged in activity such as driving, eating, or making phone calls and later having no memory of the activity. If this happens to you, stop taking zolpidem and talk with your doctor about another treatment for your sleep disorder. Zolpidem may impair your thinking or reactions. You may still feel sleepy the morning after taking the medication. Wait at least 4 hours or until you are fully awake before you drive, operate machinery, pilot an airplane, or do anything that requires you to be awake and alert. Do not take this medicine if you have consumed alcohol during the day or just before bed. Zolpidem may be habit-forming and should be used only by the person it was prescribed for. Keep the medication in a secure place where others cannot get to it.

It is dangerous to try and purchase zolpidem on the Internet or from vendors outside of the United States. Medications distributed from Internet sales may contain dangerous ingredients, or may not be distributed by a licensed pharmacy. Samples of zolpidem purchased on the Internet have been found to contain haloperidol (Haldol), a potent antipsychotic drug with dangerous side effects. For more information, contact the U.S. Food and Drug Administration (FDA) or visit www.fda.gov/buyonlineguide.

What should I discuss with my healthcare provider before taking zolpidem? Some people using this medicine have engaged in activity such as driving, eating, or making phone calls and later having no memory of the activity. If this happens to you, stop taking zolpidem and talk with your doctor about another treatment for your sleep disorder. You should not use this medication if you are allergic to zolpidem. Zolpidem tablets may contain lactose. Use caution if you are sensitive to lactose.

To make sure you can safely take zolpidem, tell your doctor if you have any of these other conditions:

kidney disease; liver disease;

lung disease such as asthma, bronchitis, emphysema, or chronic obstructive pulmonary disease (COPD);

sleep apnea (breathing stops during sleep);

myasthenia gravis;

a history of depression, mental illness, or suicidal thoughts; or

a history of drug or alcohol addiction.

Zolpidem may be habit forming and should be used only by the person it was prescribed for. Never share zolpidem with another person, especially someone with a history of drug abuse or addiction. Keep the medication in a place where others cannot get to it. FDA pregnancy category C. It is not known whether zolpidem will harm an unborn baby. Tell your doctor if you are pregnant or plan to become pregnant while using this medication. Zolpidem can pass into breast milk and may harm a nursing baby. Do not use this medication without telling your doctor if you are breast-feeding a baby. The sedative effects of zolpidem may be stronger in older adults. Do not give this medicine to anyone younger than 18 years of age.

It is dangerous to try and purchase zolpidem on the Internet or from vendors outside of the United States. Medications distributed from Internet sales may contain dangerous ingredients, or may not be distributed by a licensed pharmacy. Samples of zolpidem purchased on the Internet have been found to contain haloperidol (Haldol), a potent antipsychotic drug with dangerous side effects. For more information, contact the U.S. Food and Drug Administration (FDA) or visit www.fda.gov/buyonlineguide.

How should I take zolpidem?

Take exactly as prescribed by your doctor. Do not take in larger or smaller amounts or for longer than recommended. Follow the directions on your prescription label.

Zolpidem comes with patient instructions for safe and effective use. Follow these directions carefully. Ask your doctor or pharmacist if you have any questions.

Never take Ambien, Edluar, or Zolpimist if you do not have a full 7 to 8 hours to sleep before being active again.

Do not take Intermezzo for middle-of-the-night insomnia unless you have 4 hours of sleep time left before being active.

Zolpidem is for short-term use only. Tell your doctor if your insomnia symptoms do not improve, or if they get worse after using this medication for 7 to 10 nights in a row. Do not take zolpidem for longer than 4 or 5 weeks without your doctor's advice. Do not stop using zolpidem suddenly after long-term use, or you could have unpleasant withdrawal symptoms. Ask your doctor how to avoid withdrawal symptoms when you stop using the medicine.

Insomnia symptoms may also return after you stop taking zolpidem. These symptoms may seem to be even worse than before you started taking the medication. Call your doctor if you still have worsened insomnia after the first few nights without taking zolpidem.

Do not crush, chew, or break an Ambien CR tablet. Swallow the pill whole. Breaking the pill may cause too much of the drug to be released at one time.

Do not swallow the Edluar or Intermezzo tablet whole. Place the tablet under your tongue and allow it to dissolve in your mouth without water.

Spray Zolpimist directly into your mouth over your tongue. Prime the spray before the first use by pumping 5 test sprays into the air, away from your face. Prime the spray with 1 test spray if it has not been used for longer than 14 days.

Store at room temperature away from moisture and heat. Do not freeze. Keep the Zolpimist bottle upright when not in use.

See also: Zolpidem dosage (in more detail)

What happens if I miss a dose?

Since zolpidem is taken only at bedtime, you will not be on a frequent dosing schedule.

What happens if I overdose? Seek emergency medical attention or call the Poison Help line at 1-800-222-1222. An overdose of zolpidem can be fatal when it is taken together with other medications that can cause drowsiness.

Overdose symptoms may include sleepiness, confusion, shallow breathing, feeling light-headed, fainting, or coma.

What should I avoid while taking zolpidem? Zolpidem may impair your thinking or reactions. You may still feel sleepy the morning after taking the medication. Wait at least 4 hours or until you are fully awake before you drive, operate machinery, pilot an airplane, or do anything that requires you to be awake and alert.

Avoid taking zolpidem during travel, such as to sleep on an airplane. You may be awakened before the effects of the medication have worn off. Amnesia (forgetfulness) is more common if you do not get a full 7 to 8 hours of sleep after taking zolpidem.

Do not take this medicine if you have consumed alcohol during the day or just before bed. Zolpidem side effects Zolpidem may cause a severe allergic reaction. Stop taking zolpidem and get emergency medical help if you have any of these signs of an allergic reaction: hives; difficulty breathing; swelling of your face, lips, tongue, or throat. Report any new or worsening symptoms to your doctor, such as: depression, anxiety, aggression, agitation, confusion, unusual thoughts, hallucinations, memory problems, changes in personality, risk-taking behavior, decreased inhibitions, no fear of danger, or thoughts of suicide or hurting yourself. Stop using zolpidem and call your doctor at once if you have a serious side effects:

chest pain, fast or irregular heartbeat, feeling short of breath;

trouble breathing or swallowing; or

feeling like you might pass out.

Less serious side effects may include:

daytime drowsiness, dizziness, weakness, feeling "drugged" or light-headed;

tired feeling, loss of coordination;

dry mouth, nose or throat irritation;

nausea, constipation, diarrhea, upset stomach;

stuffy nose, sore throat; or

headache, muscle pain.

This is not a complete list of side effects and others may occur. Call your doctor for medical advice about side effects. You may report side effects to FDA at 1-800-FDA-1088.

Zolpidem Dosing Information

Usual Adult Dose for Insomnia:

Immediate release: 10 mg orally once a day immediately before bedtime. Alternatively, the dose may be administered as one 10 mg sublingual tablet placed under the tongue to disintegrate once a day immediately before bedtime. The sublingual tablet should not be swallowed or taken with water. The recommended duration of zolpidem therapy is generally 7 to 10 days. Each metered actuation (one spray) of zolpidem tartrate oral spray delivers 5 mg of zolpidem.
Controlled release: 12.5 mg orally once a day immediately before bedtime.
Sublingual: The recommended and maximum dose is 1.75 mg SL for women and 3.5 mg SL for men only once per night (to be taken only if the patient has at least 4 hours of bedtime remaining before the planned time of waking).
If zolpidem is used daily for more than a few weeks, abrupt discontinuation is not recommended. Such cessation may precipitate symptoms of withdrawal.
The safety of immediate release zolpidem has only been established for treatment regimens of up to five weeks. Administration of immediate release zolpidem for therapies longer than five weeks is therefore not recommended.

Usual Geriatric Dose for Insomnia:

Immediate release: 5 mg once a day immediately before bedtime. Alternatively, the dose may be administered as one 5 mg sublingual tablet placed under the tongue to disintegrate. The sublingual tablet should not be swallowed or taken with water. The recommended duration of zolpidem therapy is generally 7 to 10 days. The dosage can be titrated up to 10 mg nightly if necessary depending on patient response.
Controlled release: 6.25 mg orally once a day immediately before bedtime.
Sublingual: The recommended and maximum dose is 1.75 mg only once per night (to be taken only if the patient has at least 4 hours of bedtime remaining before the planned time of waking).
If zolpidem is used daily for more than a few weeks, abrupt discontinuation is not recommended. Such cessation may precipitate symptoms of withdrawal.
The safety of immediate release zolpidem has only been established for treatment regimens of up to five weeks. Administration of immediate release zolpidem for therapies longer than five weeks is therefore not recommended.

What other drugs will affect zolpidem? You may need a lower dose of zolpidem if you take other medicines that make you sleepy (such as cold medicine, pain medication, muscle relaxants, and medicine for depression or anxiety). Tell your doctor if you are currently taking any of these medications.

Tell your doctor about all other medicines you use, especially:

chlorpromazine (Thorazine);

itraconazole (Sporanox), ketoconazole (Nizoral);

rifampin (Rifadin, Rimactane, Rifater); or

antidepressants such as imipramine (Tofranil), or sertraline (Zoloft).

This list is not complete and other drugs may interact with zolpidem. Tell your doctor about all medications you use. This includes prescription, over-the-counter, vitamin, and herbal products. Do not start a new medication without telling your doctor.

More zolpidem resources Zolpidem Side Effects (in more detail) Zolpidem Dosage Zolpidem Use in Pregnancy & Breastfeeding Drug Images Zolpidem Drug Interactions Zolpidem Support Group 304 Reviews for Zolpidem - Add your own review/rating zolpidem Oral, Oromucosal Advanced Consumer (Micromedex) - Includes Dosage Information Zolpidem Prescribing Information (FDA) Zolpidem MedFacts Consumer Leaflet (Wolters Kluwer) Ambien Consumer Overview Ambien Monograph (AHFS DI) Ambien Prescribing Information (FDA) Ambien CR Extended-Release Tablets MedFacts Consumer Leaflet (Wolters Kluwer) Ambien CR Prescribing Information (FDA) Edluar Consumer Overview Edluar MedFacts Consumer Leaflet (Wolters Kluwer) Edluar Prescribing Information (FDA) Intermezzo Consumer Overview ZolpiMist Consumer Overview Zolpimist Prescribing Information (FDA) Zolpimist Oral Spray MedFacts Consumer Leaflet (Wolters Kluwer) Compare zolpidem with other medications Insomnia Where can I get more information? Your pharmacist can provide more information about zolpidem.

See also: zolpidem side effects (in more detail)


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Echinocandins


A drug may be classified by the chemical type of the active ingredient or by the way it is used to treat a particular condition. Each drug can be classified into one or more drug classes.

Echinocandins are a class of antifungal drugs that target the fungal cell wall. They are lipopeptide molecules that noncompetitively inhibit (1,3) beta-d-glucan synthase enzyme. This enzyme forms glucan, a major component of the fungal cell wall therefore by inhibiting its synthesis fungal cell walls are damaged.

See also

Medical conditions associated with echinocandins:

Aspergillosis, InvasiveCandida Infections, SystemicEsophageal CandidiasisFebrile NeutropeniaFungal Infection Prophylaxis Drug List:/tags/cancidas/
Mycamine
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Quinidine Sulfate


Pronunciation: KWIN-ih-deen
Generic Name: Quinidine Sulfate
Brand Name: Generic only. No brands available.

Quinidine Sulfate is associated with an increased risk of death when used to treat non-life-threatening irregular heartbeat. This risk may be greater if you have structural heart disease. Talk with your doctor for more information.


Quinidine Sulfate is used for:

Treating and preventing certain abnormal heart rhythms.

Quinidine Sulfate is an antiarrhythmic. It works by stabilizing the heart rhythm in conditions in which the heart is beating too fast or in an irregular rhythm (antiarrhythmic effect).

Do NOT use Quinidine Sulfate if: you are allergic to any ingredient in Quinidine Sulfate you have certain severe, uncontrolled, abnormal heart rhythms; muscle weakness due to myasthenia gravis; or you have previously developed unusual bruising while using Quinidine Sulfate or similar medicines you are taking astemizole, codeine, cisapride, a class III antiarrhythmic medicine (eg, amiodarone), terfenadine, itraconazole, a ketolide antibiotic (eg, telithromycin), a macrolide antibiotic (eg, erythromycin), a nondepolarizing muscle relaxant (eg, pancuronium), a phenothiazine (eg, chlorpromazine), a phosphodiesterase type 5 inhibitor (eg, sildenafil), pimozide, a quinolone antibiotic (eg, ciprofloxacin), succinylcholine, terfenadine, or voriconazole

Contact your doctor or health care provider right away if any of these apply to you.

Before using Quinidine Sulfate:

Some medical conditions may interact with Quinidine Sulfate. Tell your doctor or pharmacist if you have any medical conditions, especially if any of the following apply to you:

if you are pregnant, planning to become pregnant, or are breast-feeding if you are taking any prescription or nonprescription medicine, herbal preparation, or dietary supplement if you have allergies to medicines, foods, or other substances if you have a history of liver or kidney disease; congestive heart failure, heart block, QT prolongation, or other heart problems; low blood pressure; high or low blood calcium levels; decreased blood platelets; or digitalis intoxication

Some MEDICINES MAY INTERACT with Quinidine Sulfate. Tell your health care provider if you are taking any other medicines, especially any of the following:

Barbiturates (eg, phenobarbital), hydantoins (eg, phenytoin), nifedipine, or rifampin because the effectiveness of Quinidine Sulfate may be decreased Amiloride, amiodarone, carbonic anhydrase inhibitors (eg, acetazolamide), cimetidine, itraconazole, ketoconazole, thiazide diuretics (eg, hydrochlorothiazide), verapamil, or voriconazole because side effects, such as increased risk of low blood pressure or heart conduction disturbances and racing heart rate, dizziness, or fainting, may occur Arsenic, astemizole, cisapride, class III antiarrhythmics (eg, amiodarone), dofetilide, droperidol, haloperidol, HIV protease inhibitors (eg, indinavir), ketolide antibiotics (eg, telithromycin), macrolide antibiotics (eg, erythromycin), phenothiazines (eg, chlorpromazine), phosphodiesterase type 5 inhibitors (eg, sildenafil), pimozide, quinolones, streptogramins (eg, pristinamycin), terfenadine, or ziprasidone because the actions and side effects of Quinidine Sulfate and these medicines may be increased Anticoagulants (eg, warfarin), aripiprazole, beta-adrenergic blockers (eg, metoprolol), digitoxin, digoxin, nondepolarizing muscle relaxants (eg, pancuronium), norepinephrine reuptake inhibitors (eg, atomoxetine), procainamide, propafenone, or succinylcholine because the actions or side effects of these medicines may be increased Anticholinesterases (eg, pyridostigmine) or narcotic analgesics (eg, codeine) because the effectiveness of these medicines may be decreased

This may not be a complete list of all interactions that may occur. Ask your health care provider if Quinidine Sulfate may interact with other medicines that you take. Check with your health care provider before you start, stop, or change the dose of any medicine.

How to use Quinidine Sulfate:

Use Quinidine Sulfate as directed by your doctor. Check the label on the medicine for exact dosing instructions.

It is best to take Quinidine Sulfate on an empty stomach at least 1 hour before or 2 hours after eating. If stomach upset occurs, you may take it with food to reduce stomach irritation. Take Quinidine Sulfate with a full glass of water (8 oz/240 mL). Do not lie down for 30 minutes after taking Quinidine Sulfate. Take Quinidine Sulfate regularly to receive the most benefit from it. Continue to use Quinidine Sulfate even if you feel well. Do not miss any doses. Eating grapefruit or drinking grapefruit juice may affect the amount of Quinidine Sulfate in your blood. Talk with your doctor before including grapefruit or grapefruit juice in your diet. If you miss a dose of Quinidine Sulfate, take it as soon as possible. If it is almost time for our next dose, skip the missed dose and go back to your regular dosing schedule. Do not take 2 doses at once.

Ask your health care provider any questions you may have about how to use Quinidine Sulfate.

Important safety information: Quinidine Sulfate may cause dizziness or blurred vision. Do not drive, operate machinery, or do anything else that could be dangerous until you know how you react to Quinidine Sulfate. Quinidine Sulfate may cause increased sensitivity to the sun. Avoid exposure to the sun, sunlamps, or tanning booths until you know how you react to Quinidine Sulfate. Use a sunscreen or protective clothing if you must be outside for a prolonged period. Do not suddenly stop taking Quinidine Sulfate without checking with your doctor. Before you have any medical or dental treatments, emergency care, or surgery, tell the doctor or dentist that you are using Quinidine Sulfate. LAB TESTS, including heart function tests, may be performed to monitor your progress or to check for side effects. Be sure to keep all doctor and lab appointments. Use Quinidine Sulfate with extreme caution in CHILDREN. Safety and effectiveness have not been confirmed. PREGNANCY and BREAST-FEEDING: If you become pregnant, discuss with your doctor the benefits and risks of using Quinidine Sulfate during pregnancy. Quinidine Sulfate is excreted in breast milk. Do not breast-feed while you are taking Quinidine Sulfate. Possible side effects of Quinidine Sulfate:

All medicines may cause side effects, but many people have no, or minor, side effects. Check with your doctor if any of these most COMMON side effects persist or become bothersome:

Blurred vision; diarrhea; heartburn; nausea; stomach discomfort; vomiting.

Seek medical attention right away if any of these SEVERE side effects occur:

Severe allergic reactions (rash; hives; itching; difficulty breathing; tightness in the chest; swelling of the mouth, face, lips, or tongue); dark urine; dizziness or lightheadedness; fainting; fast, slow, or irregular heartbeat; headache; hearing changes or loss of hearing; mood or mental changes; pale stools; ringing in ears; severe or persistent stomach pain; vision changes; yellowing of the skin or eyes.

This is not a complete list of all side effects that may occur. If you have questions about side effects, contact your health care provider. Call your doctor for medical advice about side effects. To report side effects to the appropriate agency, please read the Guide to Reporting Problems to FDA.

See also: Quinidine Sulfate side effects (in more detail)

If OVERDOSE is suspected:

Contact 1-800-222-1222 (the American Association of Poison Control Centers), your local poison control center, or emergency room immediately. Symptoms may include diarrhea; disturbed vision; fainting; fast or slow heartbeat; low blood pressure; ringing in the ears; trouble breathing; trouble walking.

Proper storage of Quinidine Sulfate:

Store Quinidine Sulfate between 59 and 86 degrees F (15 and 30 degrees C). Store away from heat, moisture, and light. Do not store in the bathroom. Keep Quinidine Sulfate out of the reach of children and away from pets.

General information: If you have any questions about Quinidine Sulfate, please talk with your doctor, pharmacist, or other health care provider. Quinidine Sulfate is to be used only by the patient for whom it is prescribed. Do not share it with other people. If your symptoms do not improve or if they become worse, check with your doctor. Check with your pharmacist about how to dispose of unused medicine.

This information is a summary only. It does not contain all information about Quinidine Sulfate. If you have questions about the medicine you are taking or would like more information, check with your doctor, pharmacist, or other health care provider.

Issue Date: February 1, 2012 Database Edition 12.1.1.002 Copyright © 2012 Wolters Kluwer Health, Inc. More Quinidine Sulfate resources Quinidine Sulfate Side Effects (in more detail) Quinidine Sulfate Dosage Quinidine Sulfate Use in Pregnancy & Breastfeeding Drug Images Quinidine Sulfate Drug Interactions Quinidine Sulfate Support Group 0 Reviews for Quinidine Sulfate - Add your own review/rating Quinidine Sulfate Monograph (AHFS DI) Cardioquin Advanced Consumer (Micromedex) - Includes Dosage Information Quin-G Concise Consumer Information (Cerner Multum) Quin-Release Concise Consumer Information (Cerner Multum) Quinidine Prescribing Information (FDA) Quinidine Professional Patient Advice (Wolters Kluwer) Compare Quinidine Sulfate with other medications Arrhythmia Malaria
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Allergy Relief Tablets


loratadine
Dosage Form: tablet
Drug Facts Active ingredient

loratadine 10mg

Purpose

antihistamine

Uses

temporarily relieves these symptoms due to hay fever or other upper respiratory allergies:

• runny nose • itchy, watery eyes • sneezing • itching of the nose or throat

Warnings Adverse Reactions Do Not Use

Do not use if you have ever had an allergic reaction to this product or any of its ingredients.

Ask Doctor

Ask a doctor before use if you have liver or kidney disease. Your doctor should determine if you need a different dose.

When Using

When using this product do not take more than directed. Taking more than directed may cause drowsiness.

Stop Use

Stop use and ask a doctor if an allergic reaction to this product occurs. Seek medical help right away.

Pregnancy or Breast Feeding

If pregnant or breast-feeding, ask a health professional before use.

Keep Out of Reach of Children

Keep out of reach of children.

Overdose

In case of overdose, get medical help or contact a Poison Control Center right away.

Other Information safety sealed: do not use if the imprinted bottle seal with “sealed for your protection” is open or torn (for bottle carton only) safety sealed: do not use if the imprinted blister unit is open or torn (for blister carton only) store at 20-25°C (68-77°F) (see USP Controlled Room Temperature) Directions adults and children 6 years and over 1 tablet daily; not more than 1 tablet in 24 hours children under 6 years of age ask a doctor consumers with liver or kidney disease ask a doctor Inactive ingredients

lactose monohydrate, magnesium stearate, microcrystalline cellulose, sodium starch glycolate

Questions

call 1-800-452-0051

 

 Distributed by Target Corp.

Minneapolis, MN 55403

copyright 2009 Target Brands, Inc.

All Rights Persevered

Principal Display

Target


ALLERGY RELIEF MEDICATION 
loratadine  tablet Product Information Product Type HUMAN OTC DRUG NDC Product Code (Source) 11673-315 Route of Administration ORAL DEA Schedule      Active Ingredient/Active Moiety Ingredient Name Basis of Strength Strength LORATADINE (LORATADINE) LORATADINE 10 mg Inactive Ingredients Ingredient Name Strength CELLULOSE, MICROCRYSTALLINE   LACTOSE MONOHYDRATE   MAGNESIUM STEARATE   SODIUM STARCH GLYCOLATE TYPE A POTATO   Product Characteristics Color WHITE Score no score Shape ROUND Size 6mm Flavor Imprint Code GG;296 Contains          Packaging # NDC Package Description Multilevel Packaging 1 11673-315-10 2 BLISTER PACK In 1 CARTON contains a BLISTER PACK 1 5 TABLET In 1 BLISTER PACK This package is contained within the CARTON (11673-315-10) 2 11673-315-40 4 BLISTER PACK In 1 CARTON contains a BLISTER PACK 2 10 TABLET In 1 BLISTER PACK This package is contained within the CARTON (11673-315-40) 3 11673-315-18 1 BOTTLE In 1 CARTON contains a BOTTLE 3 180 TABLET In 1 BOTTLE This package is contained within the CARTON (11673-315-18) 4 11673-315-60 6 BLISTER PACK In 1 CARTON contains a BLISTER PACK 4 10 TABLET In 1 BLISTER PACK This package is contained within the CARTON (11673-315-60) 5 11673-315-30 3 BLISTER PACK In 1 CARTON contains a BLISTER PACK 5 10 TABLET In 1 BLISTER PACK This package is contained within the CARTON (11673-315-30) 6 11673-315-15 3 BLISTER PACK In 1 CARTON contains a BLISTER PACK 6 5 TABLET In 1 BLISTER PACK This package is contained within the CARTON (11673-315-15)
Marketing Information Marketing Category Application Number or Monograph Citation Marketing Start Date Marketing End Date NDA NDA075209 01/31/2010
Labeler - Target Brands, Inc. (006961700) Revised: 09/2010Target Brands, Inc. More Allergy Relief Tablets resources Allergy Relief Tablets Side Effects (in more detail) Allergy Relief Tablets Dosage Allergy Relief Tablets Use in Pregnancy & Breastfeeding Allergy Relief Tablets Drug Interactions 0 Reviews for Allergy Reliefs - Add your own review/rating Compare Allergy Relief Tablets with other medications Hay Fever Urticaria
read more / Download


Nighttime Sleepaid



Dosage Form: tablet
CVS Pharmacy, Inc. Nighttime Sleep Aid Tablets Drug Facts Active ingredient (in each tablet)

Doxylamine succinate 25 mg

Purpose

Nighttime sleep-aid

Uses helps to reduce difficulty in falling asleep Warnings

Ask a doctor before use if you have

a breathing problem such as asthma, emphysema or chronic bronchitis glaucoma trouble urinating due to an enlarged prostate gland Do not give

to children under 12 years of age

Ask a doctor or pharmacist before use if you are

taking any other drugs

When using this product avoid alcoholic beverages take only at bedtime Stop use and ask a doctor if sleeplessness persists continuously for more than two weeks. Insomnia may be a symptom of serious underlying medical illness. If pregnant or breast-feeding,

ask a health professional before use.

Keep out of reach of children.

In case of overdose, get medical help or contact a Poison Control Center right away.

Directions adults and children 12 years of age and over: take one tablet 30 minutes before going to bed; take once daily or as directed by a doctor children under 12 years of age: do not use Other information store at 68°-77°F (20°-25°C) retain in carton until time of use see carton end panel for lot number and expiration date Inactive ingredients

dibasic calcium phosphate, FD&C blue no. 1 aluminum lake, magnesium stearate, microcrystalline cellulose, sodium starch glycolate

Questions or comments?

1-800-719-9260

Principal Display Panel

Compare to the active ingredient in Unisom® SleepTabs®

Nighttime

Sleep Aid

Doxylamine Succinate Tablets, 25 mg USP

Nighttime Sleep Aid

Fall Asleep Fast

Safe. Proven Effective

Just One Tablet Per Dose

Actual Size

Nighttime Sleep Aid Tablets Carton


NIGHTTIME SLEEP AID 
doxylamine succinate  tablet Product Information Product Type HUMAN OTC DRUG NDC Product Code (Source) 59779-441 Route of Administration ORAL DEA Schedule      Active Ingredient/Active Moiety Ingredient Name Basis of Strength Strength DOXYLAMINE SUCCINATE (DOXYLAMINE) DOXYLAMINE SUCCINATE 25 mg Inactive Ingredients Ingredient Name Strength No Inactive Ingredients Found Product Characteristics Color BLUE Score no score Shape OVAL Size 10mm Flavor Imprint Code L441 Contains          Packaging # NDC Package Description Multilevel Packaging 1 59779-441-64 2 BLISTER PACK In 1 CARTON contains a BLISTER PACK 1 16 TABLET In 1 BLISTER PACK This package is contained within the CARTON (59779-441-64)
Marketing Information Marketing Category Application Number or Monograph Citation Marketing Start Date Marketing End Date ANDA ANDA040167 07/23/1997
Labeler - CVS Pharmacy (062312574) Revised: 06/2009CVS Pharmacy
More Nighttime Sleepaid resources Nighttime Sleepaid Side Effects (in more detail)Nighttime Sleepaid Use in Pregnancy & BreastfeedingDrug ImagesNighttime Sleepaid Drug InteractionsNighttime Sleepaid Support Group8 Reviews for Nighttime Sleepaid - Add your own review/rating Compare Nighttime Sleepaid with other medications AllergiesConjunctivitis, AllergicHay FeverInsomniaNasal CongestionRhinorrheaUpper Respiratory Tract Infection
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Calcium Salts


Class: Replacement Preparations
VA Class: TN420
CAS Number: 543-90-8
Brands: Alka-Mints, Calcet, Calci-Chew, Calci-Mix, Calphosan, Caltrate, Caltrate + Vitamin D, Chooz, Citracal, Citracal + D, Healthy Woman, Liqui-Cal, Os-Cal, Os-Cal +D, PhosLo, Posture, Posture-D, Titralac, Tums, Viactiv

Pharmacy Bulk Packages

Pharmacy bulk packages are for preparation of IV mixtures only.g

Not for direct IV infusion.g

Introduction

Calcium salts are used as a source of calcium, an essential nutrient cation.b

Uses for Calcium Salts Dietary Requirements (oral therapy)

For maintaining an adequate intake of calcium to support the development and preservation of bone mass at a level sufficient to prevent fractures associated with osteopenia or osteoporosis in later life and of other calcified tissues (e.g., teeth).112 126 129

Although calcium can have beneficial effects on BP, 101 102 no current rationale to supplement calcium intake solely for BP reduction.114 120 121

Adequate intakes of calcium can be accomplished through changes in food consumption behaviors, consumption of nutrient-fortified foodstuffs, use of dietary supplements, or a combination of these.112

Use fortified foodstuffs to increase or maintain intakes without major changes in food habits and use supplements in certain individuals who are at increased risk.112 In the US and Canada, calcium principally is obtained from dairy products (almost 75% of total intake).112 Other principal sources include fruits and vegetables (about 9%) and grain products (about 5%).112 In addition, many healthy individuals take dietary supplements containing calcium.112

For specific information on currently recommended Adequate Intakes (AIs) of calcium for various life-stage and gender groups, see Dosage under Dosage and Administration.b

Supplemental Therapy for Pregnant, Postmenopausal, or Nursing Women (oral therapy)

Calcium salts are used as supplemental therapy for pregnant, postmenopausal, or nursing women.b

In general, any calcium salt may be used for chronic replacement therapy.b

Phosphate salts of calcium are efficacious in pregnant, nursing, or osteoporotic patients who usually require both calcium and phosphorus supplements, but they should not be used in hypocalcemic-hyperphosphatemic states (e.g., hypoparathyroidism, renal failure).b

Hypocalcemia (parenteral and oral therapy)

Calcium salts are used as a source of calcium cation for the treatment or prevention of calcium depletion when dietary measures are inadequate.b Conditions associated with calcium deficiency include hypoparathyroidism, achlorhydria, chronic diarrhea, vitamin D deficiency, steatorrhea, sprue, pregnancy and lactation, menopause, pancreatitis, renal failure, alkalosis, and hyperphosphatemia.b

IV calcium chloride is considered the calcium salt of choice to prevent hypocalcemia during transfusions with citrated blood.b In addition to being irritating, however, the chloride salt is acidifying and generally should not be used when acidosis coincides with hypocalcemia (e.g., renal failure).b

The calcium glycerophosphate and calcium lactate fixed-combination injection is used IM to increase serum calcium concentrations.142

Administration of certain drugs (e.g., some diuretics, anticonvulsants) may sometimes result in hypocalcemia, which may warrant calcium replacement therapy.b

Calcium is administered in long-term electrolyte replacement regimens.b

Use of calcium salts should not preclude the use of other measures intended to correct the underlying cause of calcium depletion.b

Vitamin D analogs may be administered concomitantly with oral calcium salts for the treatment of chronic hypocalcemia, especially when caused by vitamin D deficiency.b

Calcium salts may be used orally for the treatment of hypocalcemia secondary to the administration of anticonvulsant drugs.b

Hypocalcemic Tetany (IV therapy)

IV calcium gluconate is considered the salt of choice for the treatment of acute hypocalcemia.b

Calcium salts are used to treat acute hypocalcemic tetany secondary to renal failure, hypoparathyroidism, premature delivery, and/or maternal diabetes mellitus in infants, and poisoning with magnesium, oxalic acid, radiophosphorus, carbon tetrachloride, fluoride, phosphate, strontium, or radium.b

Hypoparathyroidism, Chronic (oral therapy)

Calcium salts may be used for treatment of chronic hypoparathyroidism.b

Latent Tetany (oral therapy)

Calcium salts may be used for the treatment of latent tetany.b

Osteoporosis Prevention (oral therapy)

For women whose dietary intake of calcium is limited, supplementation with oral calcium salts is recommended for the prevention of primary osteoporosis.100 126

Daily calcium requirement is about 1 g in premenopausal women and in women receiving estrogen therapy and about 1.5 g in postmenopausal women who are not receiving supplemental estrogen therapy.100 126

While not as effective as a regimen of estrogens and exercise, the addition of calcium to a regimen of exercise appears be more effective than exercise alone in preventing or slowing bone loss in postmenopausal women considered at risk for osteoporotic fracture because of low bone density, and generally appears to be better tolerated than the estrogen-exercise regimen.111 126

Intake of elemental calcium of 1–1.5 g daily, beginning well before the menopause, is believed by some clinicians to reduce the incidence of osteoporosis in postmenopausal women; increased calcium intake may also prevent or diminish age-related bone loss in men.100 126

Osteoporosis Treatment (oral therapy)

Calcium salts may be used for treatment of osteoporosis.b

Osteomalacia (oral therapy)

Calcium salts may be used for treatment of osteomalacia.b

Anticonvulsant-induced Hypocalcemia (oral therapy)

Calcium salts may be used for treatment of rickets, latent tetany, and hypocalcemia secondary to the administration of anticonvulsant drugs.b

Rickets (oral therapy)

Calcium salts may be used for treatment of rickets.b

Corticosteroid-induced Osteoporosis (oral therapy)

Corticosteroid-induced osteoporosis results in part from decreased GI absorption of calcium and increased urinary calcium excretion; attempts at normalizing calcium balance may limit the extent of bone loss during systemic corticosteroid therapy.119

Maintain an adequate calcium intake of about 1.5 g of elemental calcium daily in adults receiving chronic systemic corticosteroid therapy.119

Hyperphosphatemia in Chronic Renal Failure (oral therapy)

Calcium acetate and calcium carbonate are considered the salts of choice for chronic renal failure.113 126

In addition to providing a source of calcium, calcium acetate or carbonate sequesters phosphate in the intestine by forming insoluble phosphates that are excreted fecally, thus reducing serum phosphate concentrations and secondary hyperparathyroidism.b

Calcium carbonate partially corrects metabolic acidosis which may occur in chronic renal failure.b

Because of the risk of aluminum accumulation and resultant neurotoxic and osteomalacic effects, most clinicians no longer use aluminum hydroxide to inhibit phosphorus absorption; instead calcium acetate or carbonate and/or non-calcium-, non-aluminum-, non-magnesium-containing phosphate binders (e.g., lanthanum carbonate, sevelamer hydrochloride) currently are used.127 130 131 132

When taken with meals, calcium acetate or carbonate can contribute to controlling hyperphosphatemia in chronic renal failure by binding to and inhibiting absorption of phosphates in the GI tract.113 127

Exercise caution in patients undergoing chronic hemodialysis to prevent hypophosphatemia.b

Patients with end-stage renal failure may develop hypercalcemia when calcium is administered with meals; do not give calcium supplementation concomitantly when calcium salts are used to control hyperphosphatemia in such patients.113

Progressive hypercalcemia secondary to overdose of calcium salts can occur and may require emergency treatment measures.113

Chronic hypercalcemia also may lead to vascular and other soft-tissue calcification;113 126 periodic (e.g., twice weekly) monitoring of calcium concentrations is recommended during the initial dose adjustment.113 One manufacturer recommends that the serum calcium times phosphate (Ca ? P) product should not exceed 66.113 Radiographic evaluation of a suspected anatomical region for early soft-tissue calcification may be useful.113

Hyperkalemia with Secondary Cardiotoxicity (IV therapy)

Calcium salts are used with ECG monitoring to antagonize the cardiotoxicity of hyperkalemia when the ECG shows broad QRS complexes or absent P waves.134 b

Administer parenteral calcium salts cautiously, if at all, to patients receiving cardiac glycosides (especially during cardiac resuscitation or for the treatment of hyperkalemia) or if digoxin toxicity is suspected.134 b (See Digoxin under Drug Interactions.)

CPR (IV therapy)

Calcium has been administered IV or into the ventricular cavity during cardiac resuscitation when epinephrine or isoproterenol had failed to improve weak or ineffective myocardial contraction.b j However, because of the theoretical potential for detrimental effects resulting from high concentrations of calcium and the lack of demonstrated benefit, the guidelines on CPR and emergency cardiovascular care (ECC) currently state that calcium should not be used routinely to support circulation in the setting of cardiac arrest in ACLS in adults and pediatric advanced life support (PALS) in children, except when hyperkalemia, ionized hypocalcemia (e.g., after multiple blood transfusions), or calcium-channel blocking agent toxicity is present.109 134 b

Guidelines no longer include recommendations for the use of calcium in the acute phase of CPR in neonates.109 134 b

Calcium chloride is the calcium salt of choice for cardiac resuscitation, when calcium is indicated.134 b In addition to being irritating, however, the chloride salt is acidifying and generally should not be used when acidosis coincides with hypocalcemia (e.g., renal failure).b

Aminoglycoside Neuromuscular Blockade (IV therapy)

Calcium salts are used to antagonize neuromuscular blockade† resulting from the use of aminoglycoside antibiotics (e.g., gentamicin, kanamycin, neomycin) with or without agents possessing neuromuscular blocking properties (e.g., gallamine triethiodide).b

Magnesium Intoxication (IV therapy)

Calcium gluconate may be used in the treatment of magnesium sulfate overdosage.c

Calcium gluconate is considered treatment of choice for magnesium toxicity in pregnant women with eclampsia.134 b

Myasthenia Gravis (oral therapy)

Calcium salts are used as adjunctive treatment of myasthenia gravis.b

In general, any oral calcium salt may be used for chronic replacement therapy.b

Medullary Thyroid Carcinoma (IV therapy)

Calcium infusions (“calcium challenge”) are used in medullary thyroid carcinoma†.b

Acid Indigestion (oral therapy)

Calcium carbonate or phosphate may be used for self-medication for the relief of acid indigestion, heartburn, and sour stomach.d

Colic, Renal, Biliary, Intestinal, or Lead (IV and IM therapy)

Calcium salts have been used IM or IV as adjunctive therapy to reduce spasms in renal, biliary, intestinal, or lead colic.b

Zollinger-Ellison Syndrome, Diagnosis (IV therapy)

Calcium infusions (“calcium challenge”) are used to diagnose the Zollinger-Ellison syndrome†.b

Eaton-Lambert Syndrome (oral therapy)

Calcium salts are used as adjunctive treatment of the Eaton-Lambert syndrome.b

In general, any oral calcium salt may be used for chronic replacement therapy.b

Insect Bites and Other Sensitivity Reactions (IV therapy)

Calcium salts have been used IV as adjuncts to relieve muscle cramps in the treatment of insect bites or stings (e.g., black widow spider) or to decrease capillary permeability in sensitivity reactions characterized by urticaria or angioedema and in allergic conditions, including nonthrombocytopenic purpura, dermatitis herpetiformis, drug-induced pruritus, hay fever, and asthma.b

Preeclampsia (oral therapy)

Although some evidence suggested a beneficial effect of calcium supplementation on preeclampsia,117 118 125 a large, well-designed study did not confirm a beneficial effect of calcium supplementation in preventing preeclampsia during pregnancy.114 117 However, these findings do not obviate adequate dietary calcium intake during pregnancy nor do they address whether adequate or increased calcium intake can affect blood pressure favorably in pregnant women.105 118 125

?-Adrenergic or Calcium-channel Blocking Agent Overdosage (IV therapy)

Some experts state that calcium salts may be considered in the treatment of bradycardia or shock associated with calcium-channel blocking agent-induced toxicity.134 b

These experts state that there is insufficient evidence to recommend for or against the use of calcium in ?-adrenergic blocking agent toxicity, but that calcium salts may be considered in the treatment of bradycardia or shock.134 b

Diuresis (oral therapy)

Calcium chloride, an acid-forming salt, has been used to promote diuresis, however, because it is irritating and loses effectiveness after a few days, it is rarely used for this effect.b

Calcium Salts Dosage and Administration Administration

Administer calcium orally (as acetate, carbonate, citrate, gluconate, lactate, or phosphate salt) or IV (as chloride or gluconate salt).134 b j

The fixed combination of calcium glycerophosphate and calcium lactate is injected IM.142

In extreme cardiac emergencies, calcium chloride has been administered intracardially into the ventricular cavity.b j

For ACLS during CPR in pediatric patients, calcium chloride administration via central venous catheter is preferred because of the risk of sclerosis or infiltration with a peripheral venous line.134 b

For ACLS during CPR in pediatric patients, calcium chloride also may be administered by intraosseous injection†; onset of action and systemic concentrations are comparable to those achieved with central venous administration.134 b

Oral Administration

Administer acetate, carbonate, citrate, gluconate, lactate, and phosphate salts of calcium orally.b

Administer most oral calcium supplements 1–1.5 hours after meals or with a demulcent (e.g., milk).112 b However, calcium carbonate powder generally should be administered with meals, since mixing the powder with food for administration is recommended.b

Calcium salts used to bind dietary phosphate in patients with end-stage renal disease should be administered with meals (e.g., 10–15 minutes before, or during, the meal).130

IV Administration

Calcium chloride or gluconate may be administered IV.b j

Calcium gluconate usually is administered IV as a 10% solution and calcium chloride as a 2–10% solution.b j

When injected IV, administer calcium salts slowly through a small needle into a large vein to avoid too rapid an increase in serum calcium and extravasation of calcium solution into the surrounding tissue with resultant necrosis.b

Following IV injections, the patient should remain recumbent for a short time.b

Close monitoring of serum calcium concentrations is essential during IV administration of calcium.b

Children: Calcium salts should not be administered through scalp veins; oral administration of calcium supplements or calcium-rich foods should replace IV calcium therapy as soon as possible.b

Dilution

Usually, administer IV undiluted.a b c

Parenteral calcium salts also may be administered in a compatible large-volume IV infusion fluid.b (See Solution Compatibility under Compatibility.)

Pharmacy bulk packages are for preparing IV admixtures only.g

Rate of Administration

Administer IV calcium injections slowly at a rate not exceeding 0.7–1.8 mEq/minute.b

Stop the injection if the patient complains of discomfort.b

Pharmacy bulk packages must not be infused IV directly.g

Administer pediatric dose for CPR by slow IV injection over 10–20 seconds.b

IM or Sub-Q Injection

Calcium chloride should not be injected IM or into subcutaneous or perivascular tissue, since severe necrosis and sloughing may occur.b

Although other calcium salts may cause mild to severe local reactions, they generally are less irritating than calcium chloride.b (See Cautions.)

Although some manufacturers previously stated that calcium gluconate could be injected IM when IV administration was not possible,b manufacturers of calcium gluconate currently state that the drug should not be injected IM or into subcutaneous tissue because of the potential for severe local reactions.140 141

The fixed-combination of calcium glycerophosphate and calcium lactate is injected IM.142

Intracardiac Injection

Limit intracardiac injection to personnel well trained in the technique and generally use only during open cardiac massage or when other routes of administration are persistently inaccessible.109

Inject into the left ventricular chamber.109

Follow intracardiac administration by external cardiac massage to ensure entry of the drug into the coronary circulation.

Administration Risks

Hazards include coronary artery laceration, cardiac tamponade, pneumothorax, and the need to interrupt external chest compressions and ventilation during the period of administration.109

Dosage

Dosage of the oral calcium supplements usually is expressed in g or mg of elemental calcium and depends on the requirements of the individual patient.b

Dosage of parenteral calcium replacements usually is expressed as mEq of calcium and depends on individual patient requirements.b

One mEq of elemental calcium is equivalent to 20 mg.b

The calcium content of the various calcium salts is approximately:b

Calcium Salt

Calcium Content

calcium acetate

253 mg (12.7 mEq) per g

calcium carbonate

400 mg (20 mEq) per g

calcium chloride

270 mg (13.5 mEq) per g

calcium citrate

211 mg (10.6 mEq) per g

calcium gluceptate

82 mg (4.1 mEq) per g

calcium gluconate

90 mg (4.5 mEq) per g

calcium glycerophosphate

191 mg (9.6 mEq) per g

calcium lactate

130 mg (6.5 mEq) per g

calcium phosphate dibasic anhydrous

290 mg (14.5 mEq) per g

calcium phosphate dibasic dihydrate

230 mg (11.5 mEq) per g

calcium phosphate tribasic

400 mg (20 mEq) per g

Oral calcium supplements usually are administered in 3 or 4 divided doses daily.b

Optimum calcium absorption may require supplemental vitamin D in individuals with inadequate vitamin D intake, those with impaired renal activation of the vitamin, or those not receiving adequate exposure to sunlight.112 116

Pediatric Patients Dietary Requirements Oral

Because hypocalcemia is relatively common in neonates, special evaluation of calcium requirements may be needed for some neonates.112

Adequate Intake (AI) of elemental calcium currently recommended by the National Academy of Sciences (NAS) in healthy children:112

Infants <6 Months of Age:

210 mg daily when the source is human milk (i.e., for breast-fed infants); 315 mg daily for infants receiving cow milk-based formula.112

Infants 6–12 Months of Age:

270 mg daily when the source is human milk and solid foods; 335 mg daily for infants receiving cow milk-based formula.112

Children 1–3 Years of Age:

500 mg daily.b

Children 4–8 Years of Age:

800 mg daily.b

Children 9–18 Years of Age:

1.3 g daily.112

Infants fed with various specialty formulas, including soy protein-based and protein hydrolysate formulas, should receive an additional 20% increase in calcium intake compared with infants receiving cow milk-based formulas due to lower calcium bioavailability associated with various specialty formulas.112

Give special consideration for different calcium requirements in children with chronic illnesses such as juvenile rheumatologic conditions, renal disease, liver failure, and certain endocrine disorders, including type 1 (insulin-dependent) diabetes mellitus.112

Hypocalcemia

Calcium gluconate usually is administered IV as a 10% solution and calcium chloride as a 2–10% solution.b j

Calcium replacement requirements can be estimated by clinical condition and/or serum calcium determinations.b

Prevention Oral

Neonates: Usually, 50–150 mg/kg of elemental calcium daily; do not exceed 1 g daily.b

Children: Usually, 45–65 mg/kg of elemental calcium daily.b

Treatment When Prompt Elevation of Serum Calcium Is Required IV

Infants: <0.93 mEq of calcium; may be repeated every 1–3 days depending on the patient’s response.140 141 b

Children: Usually, initial dose of 0.93–2.3 mEq of calcium; may be repeated every 1–3 days depending on the patient’s response.140 141 b

Alternatively, one manufacturer recommends a pediatric IV calcium dose of 0.272 mEq/kg, up to a maximum total daily dosage of 1.36–13.6 mEq, in the treatment of hypocalcemic disorders.138

Hypocalcemic Tetany IV

Neonates: May be treated with divided doses of calcium totaling about 2.4 mEq/kg daily.b

Children: Usually, calcium dose of 0.5–0.7 mEq/kg administered IV 3 or 4 times daily or until tetany is controlled.b

Exchange Transfusions of Citrated Blood IV

Neonates: 0.45 mEq of calcium concurrently with each 100 mL of citrated blood.b

CPR

In critically ill children, calcium chloride may provide greater bioavailability of calcium than calcium gluconate.134 b Administer appropriate dose by slow IV or intraosseous† injection.134 b

IV

Children, per PALS guidelines: 0.272 mEq/kg of calcium 128 134 as calcium chloride (0.2 mL/kg of 10% calcium chloride); this dose of 10% calcium chloride will provide 20 mg/kg of the salt and 5.4 mg/kg of elemental calcium.128 134

Calcium-channel Blocking Agent Overdosage IV

For cardiovascular emergencies in pediatric patients: 0.272 mEq/kg of calcium as 10% calcium chloride (0.2 mL/kg) may be given over 5–10 minutes; if a beneficial effect is observed, an IV calcium infusion of 0.27–0.68 mEq/kg per hour using calcium chloride may be given.134 b Monitor ionized calcium concentrations to prevent hypercalcemia.134 b

Adults Dietary Requirements Oral

Calcium replacement requirements can be estimated by clinical condition and/or serum calcium determinations.b

Prophylactic administration of calcium supplements may be necessary in some patients in order to maintain serum calcium >9 mg/dL.b

The AI of elemental calcium for healthy adults are:

Adults 19–50 Years of Age:

1 g daily.112

Adults ? 51 Years of Age:

1.2 g daily.112

Pregnant or Lactating Women:

Generally, the usual AI of calcium appropriate for their age.112

Hypocalcemia

Calcium gluconate usually is administered IV as a 10% solution and calcium chloride as a 2–10% solution.b j

Calcium replacement requirements can be estimated by clinical condition and/or serum calcium determinations.b

Prevention Oral

Usually, about 1 g of elemental calcium daily.b

Treatment Oral

Usually, 1–2 g or more of elemental calcium daily.b

IM

Usually, 0.8 mEq of calcium as the calcium glycerophosphate and calcium lactate fixed-combination preparation 1–4 times weekly or as directed by a clinician.142

Treatment When Prompt Elevation of Serum Calcium Is Required

Calcium gluconate usually is administered IV as a 10% solution and calcium chloride as a 2–10% solution.134 b j

IV

Usual initial dose of 2.3–14 mEq of calcium; doses may be repeated every 1–3 days depending on the patient’s response.136 137 138 139 140 141 b

Acute, symptomatic hypocalcemia: 4.65–9.3 mEq of calcium as 10% calcium gluconate (10–20 mL) over 10 minutes, followed by IV infusion of 27–36 mEq of calcium (58–77 mL of 10% calcium gluconate in 0.5–1 L of 5% dextrose injection).134 b Alternatively, 6.8 mEq of calcium as 10% calcium chloride (5 mL) over 10 minutes, followed by IV infusion of 50 mEq of calcium (36.6 mL of 10% calcium chloride) over 6–12 hours.134 b Measure serum calcium concentrations every 4–6 hours and maintain total serum calcium concentrations at 7–9 mg/dL.134 b

Hypocalcemic Tetany

Calcium gluconate usually is administered IV as a 10% solution and calcium chloride as a 2–10% solution.134 b j

IV

4.5–16 mEq doses of calcium, administered until therapeutic response occurs.b

Exchange Transfusions of Citrated Blood IV

About 1.35 mEq of calcium concurrently with each 100 mL of citrated blood.b

CPR IV

Per ACLS guidelines, 0.109–0.218 mEq/kg of calcium as calcium chloride; may repeat dose as necessary.109 134 b

Alternatively, 7–14 mEq of calcium as calcium chloride has been given.b

Intracardiac Injection

Usually, 2.7–5.4 mEq of calcium as calcium chloride into the ventricular cavity during cardiac resuscitation.b j

Hyperkalemia with Secondary Cardiotoxicity IV

Usually, 2.25–14 mEq of calcium while monitoring the ECG; may repeat dosage after 1–2 minutes if necessary.b

Alternatively, for hyperkalemia associated with severe potassium elevation (>7 mEq/L with toxic ECG changes), 6.8–13.6 mEq of calcium as 10% calcium chloride (5–10 mL) has been administered over 2–5 minutes to reduce the effects of potassium at the myocardial cell membrane (e.g., reduce the risk of ventricular fibrillation).134 b

Hyperphosphatemia in Chronic Renal Failure Oral

Usual initial dose of 1.334 g of calcium acetate (338 mg of calcium) with each meal;113 increase dosage gradually according to serum phosphate concentrations, provided hypercalcemia does not occur.113

Manufacturer states that most patients require about 2–2.67 g (about 500–680 mg of calcium) with each meal.113 However, some experts recommend limiting dosage of calcium provided by phosphate binders to ?1.5 g daily and limiting total calcium intake (including dietary calcium) to ?2 g daily; dialysis patients who remain hyperphosphatemic despite such therapy should receive a calcium-containing phosphate binder in combination with a non-calcium-, non-aluminum-, non-magnesium-containing phosphate binder.130

Monitor serum calcium concentrations twice weekly during initiation of therapy and subsequent dosage adjustment; also monitor serum phosphorus concentrations periodically.113

If hypercalcemia occurs, reduce dosage or withhold the salt.113 If severe hypercalcemia occurs, specific measures (e.g., hemodialysis) for the management of overdosage may be necessary.113

Zollinger-Ellison Syndrome, Diagnosis IV

Usually, 0.25 mEq/kg of calcium per hour for a 3-hour period; serum gastrin concentrations are determined 30 minutes before the infusion, at the start of the infusion, and at 30-minute intervals thereafter for 4 hours.b

In most patients with Zollinger-Ellison syndrome, preinfusion serum gastrin concentrations increase by more than 50% or by greater than 500 pg/mL during the infusion.b

Magnesium Intoxication IV

Initially, 7 mEq of calcium; adjust subsequent doses according to patient response.b

Alternatively, 6.8–13.6 mEq of calcium as 10% calcium chloride (5–10 mL) has been administered and repeated as necessary.134 b

Medullary Thyroid Carcinoma, Diagnosis IV

Usually, about 7 mEq of calcium over 5–10 minutes; in patients with medullary thyroid carcinoma, plasma calcitonin concentrations are elevated above normal basal concentrations.b

Osteoporosis Primary Prevention in Women Oral

Usually, 1–1.5 g daily of elemental calcium; 1 g daily in premenopausal women and 1.5 g daily in postmenopausal women not receiving estrogen replacement.100 126

Corticosteroid-induced Osteoporosis

To limit the extent of corticosteroid-induced osteoporosis, adults receiving chronic systemic corticosteroid therapy should maintain an adequate calcium intake.119

Oral

About 1.5 g of elemental calcium daily.119

Special Populations Hepatic Impairment

No specific dosage recommendations for hepatic impairment.a b c

Renal Impairment

No specific dosage recommendations for renal impairment.a b c

Geriatric Patients

No specific geriatric dosage recommendations.a

Cautions for Calcium Salts Contraindications

Ventricular fibrillation.b

Hypercalcemia.b

Hypophosphatemia.b

Renal calculi.b

IV administration contraindicated when serum calcium concentrations are above normal.b

Warnings/Precautions Warnings

Use calcium salts cautiously, if at all, in sarcoidosis,b renal or cardiac disease,b or patients receiving cardiac glycosides (see Digoxin under Interactions).b

Because it is acidifying, use calcium chloride cautiously in cor pulmonale,b respiratory acidosis,b renal disease,b or respiratory failure.b

Non-lipid-soluble drugs (e.g., calcium) may injure the airway; avoid endotracheal administration.134

Calcium Monitoring

Frequently perform determinations of serum calcium concentrations.b

Maintain serum calcium concentrations at 9–10.4 mg/dL (4.5–5.2 mEq/L).b Some clinicians prefer to maintain serum calcium at slightly lower concentrations.b

Usually, do not allow serum calcium concentrations to exceed 12 mg/dL.b

Determinations of urine calcium are generally unreliable and hypercalciuria can occur in the presence of hypocalcemia.b Forcing fluids may produce increased urine volume and thus prevent the formation of renal stones in patients with hypercalciuria.b

For treatment of acute, symptomatic hypocalcemia, measure serum calcium concentrations every 4–6 hours.134 Total serum calcium concentrations should be maintained at 7–9 mg/dL 134

For ACLS during CPR, measure ionized calcium concentrations because total calcium concentration does not correlate well with ionized concentration in critically ill patients.134 b

Citrated Blood Transfusion

Administration of calcium in patients who have received transfusions of citrated blood may result in higher than normal total serum calcium concentrations.b In these patients, however, most of the excess calcium is bound to citrate and is inactive; therefore, serious toxicity usually does not result.b

Discontinuing calcium when hypercalcemia occurs usually is sufficient to return serum calcium concentrations to normal.b

Local Effects

Calcium salts are irritating to tissue when administered by IM or sub-Q injection and cause mild to severe local reactions including burning, necrosis and sloughing of tissue, cellulitis, and soft tissue calcification; venous irritation may occur with IV administration.b (See IV Administration and also see IM or Sub-Q Injection, under Dosage and Administration.)

IV Injection Effects

Extravasation of calcium solution into surrounding tissues during IV injection can cause necrosis.b

Patients may complain of tingling sensations, a sense of oppression or heat waves, and a calcium or chalky taste following IV administration of calcium salts.b

Cardiovascular Effects

Rapid IV injection of calcium salts may cause vasodilation, decreased BP, bradycardia, cardiac arrhythmias, syncope, and cardiac arrest.b

Inadvertent injection of calcium into the myocardium during attempted intracardiac injection into the ventricular cavity can result in lacerated coronary arteries, cardiac tamponade or pneumothorax, and intractable ventricular fibrillation may result.b

GI Effects

Orally administered calcium salts may be irritating to the GI tract.b

Calcium salts are constipating.b

Calcium chloride, by any route of administration, produces more irritation than the other calcium salts and has been reported to cause GI hemorrhage when taken orally.b

Hypercalcemia

Hypercalcemia is rarely produced by administration of calcium alone, but may occur with large doses in patients with chronic renal failure.b

Avoid overtreatment of hypocalcemia since hypercalcemia may be more dangerous than hypocalcemia.b

Mild hypercalcemia may be asymptomatic or manifest as constipation, anorexia, nausea, and vomiting, with mental changes such as confusion, delirium, stupor, and coma becoming evident as the degree of hypercalcemia increases.113

Mild hypercalcemia usually is readily controlled by reducing calcium intake (e.g., decreasing the dose of or avoiding supplemental calcium); more severe hypercalcemia may require specific management (e.g., hemodialysis).113

Dialysis patients with chronic renal failure receiving calcium salts may require adjustments in calcium concentrations in the dialysate to reduce the risk of hypercalcemia.113 126

Long-term effects of chronic calcium administration (e.g., for hyperphosphatemia in chronic renal failure) on progression of vascular or soft-tissue calcification is unknown.113 127

Renal Calculi

High dietary intake of calcium has long been suspected as contributing to the risk of renal calculi, and restriction of calcium intake (i.e., low-calcium diets) had long been considered a reasonable measure in an attempt to prevent calculi formation in patients with idiopathic hypocalciuria.122 123 124

Recent evidence indicates that high dietary intake of calcium actually decreases the risk of symptomatic renal calculi, while intake of supplemental calcium may increase the risk of symptomatic stones.122 123 124

General Precautions Use of Fixed Combination

When used in fixed combination with other agents, consider the cautions, precautions, and contraindications associated with the concomitant agents.

Specific Populations Pregnancy

Category C.c i

Lactation

Manufacturers state that it is not known whether calcium salts are distributed into milk,a c and to observe caution with parenteral therapy.c

Calcium is an important component of human milk in women not receiving supplemental calcium salts,112 and maternal calcium supplementation does not substantially affect milk calcium concentrations since the principal source is from maternal bone resorption.112

Pediatric Use

Give calcium cautiously to children by IV route.PDH

Geriatric Use

Calcium absorption (after oral administration) may be decreased in geriatric patients.PDH

Common Adverse Effects

Constipation, nausea, vein irritation.PDH

Interactions for Calcium Salts

Consider the possibility that other drug interactions reported with antacids could occur.k

Specific Drugs and Laboratory Tests

Drug or Test

Interaction

Comments

Bisphosphonates, oral (e.g., alendronate, etidronate, ibandronate, risedronate)

Concomitant administration may result in reduced bisphosphonate absorption144 145 146 147 148 150

Administer calcium salts ?30 minutes after alendronate or risedronate, ?60 minutes after ibandronate, and not within 2 hours of etidronate administration144 145 146 147 148

Digoxin

Inotropic and toxic effects are synergistic and arrhythmias may occur (particularly when calcium is given IV)b

Avoid IV administration of calcium in patients receiving digoxin, particularly if digoxin toxicity is suspected; if necessary, calcium should be given slowly in small amounts134 b

Iron


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calcium supplement Oral, Parenteral


Class Name: calcium supplement (Oral route, Parenteral route)

Commonly used brand name(s)

In the U.S.

Ascocid Cal-C-Caps Cal-G Cal-Lac Citracal PhosLo Posture Prelief Rolaids

In Canada

Calcium Stanley

Available Dosage Forms:

Tablet, Chewable Tablet Powder for Suspension Capsule Capsule, Liquid Filled Syrup Wafer Powder Tablet, Effervescent Suspension Tablet, Extended Release Granule Uses For This Medicine

Calcium supplements are taken by individuals who are unable to get enough calcium in their regular diet or who have a need for more calcium. They are used to prevent or treat several conditions that may cause hypocalcemia (not enough calcium in the blood). The body needs calcium to make strong bones. Calcium is also needed for the heart, muscles, and nervous system to work properly.

The bones serve as a storage site for the body's calcium. They are continuously giving up calcium to the bloodstream and then replacing it as the body's need for calcium changes from day to day. When there is not enough calcium in the blood to be used by the heart and other organs, your body will take the needed calcium from the bones. When you eat foods rich in calcium, the calcium will be restored to the bones and the balance between your blood and bones will be maintained.

Pregnant women, nursing mothers, children, and adolescents may need more calcium than they normally get from eating calcium-rich foods. Adult women may take calcium supplements to help prevent a bone disease called osteoporosis. Osteoporosis, which causes thin, porous, easily broken bones, may occur in women after menopause, but may sometimes occur in elderly men also. Osteoporosis in women past menopause is thought to be caused by a reduced amount of ovarian estrogen (a female hormone). However, a diet low in calcium for many years, especially in the younger adult years, may add to the risk of developing it. Other bone diseases in children and adults are also treated with calcium supplements.

Calcium supplements may also be used for other conditions as determined by your health care professional.

A calcium "salt" contains calcium along with another substance, such as carbonate or gluconate. Some calcium salts have more calcium (elemental calcium) than others. For example, the amount of calcium in calcium carbonate is greater than that in calcium gluconate. To give you an idea of how different calcium supplements vary in calcium content, the following chart explains how many tablets of each type of supplement will provide 1000 milligrams of elemental calcium. When you look for a calcium supplement, be sure the number of milligrams on the label refers to the amount of elemental calcium, and not to the strength of each tablet.

Calcium supplement Strength of each tablet (in milligrams [mg]) Amount of elemental calcium per tablet (in milligrams) Number of tablets to provide 1000 milligrams of calcium Calcium carbonate 625
650
750
835
1250
1500 250
260
300
334
500
600
4
4
4
3
2
2
Calcium citrate 950 200 5 Calcium gluconate 500
650
1000
45
58
90 22
17
11
Calcium lactate 325
650 42
84
24
12 Calcium phosphate, dibasic 500 115 9 Calcium phosphate, tribasic 800
1600 304
608 4
2

Injectable calcium is administered only by or under the supervision of your health care professional. Other forms of calcium are available without a prescription.

Once a medicine or dietary supplement has been approved for marketing for a certain use, experience may show that it is also useful for other medical problems. Although this use is not included in product labeling, calcium supplements are used in certain patients with the following medical condition:

Hyperphosphatemia (too much phosphate in the blood) Importance of Diet

For good health, it is important that you eat a balanced and varied diet. Follow carefully any diet program your health care professional may recommend. For your specific dietary vitamin and/or mineral needs, ask your health care professional for a list of appropriate foods. If you think that you are not getting enough vitamins and/or minerals in your diet, you may choose to take a dietary supplement.

The daily amount of calcium needed is defined in several different ways.

For U.S.— Recommended Dietary Allowances (RDAs) are the amount of vitamins and minerals needed to provide for adequate nutrition in most healthy persons. RDAs for a given nutrient may vary depending on a person's age, sex, and physical condition (e.g., pregnancy). Daily Values (DVs) are used on food and dietary supplement labels to indicate the percent of the recommended daily amount of each nutrient that a serving provides. DV replaces the previous designation of United States Recommended Daily Allowances (USRDAs). For Canada— Recommended Nutrient Intakes (RNIs) are used to determine the amounts of vitamins, minerals, and protein needed to provide adequate nutrition and lessen the risk of chronic disease.

Normal daily recommended intakes in milligrams (mg) for calcium are generally defined as follows:

Persons U.S. (mg) Canada (mg) Infants birth to 3 years of age 400 to 800 250 to 550 Children 4 to 6 years of age 800 600 Children 7 to 10 years of age 800 700 to 1100 Adolescent and adult males 800 to 1200 800 to 1100 Adolescent and adult females 800 to 1200 700 to 1100 Pregnant females 1200 1200 to 1500 Breast-feeding females 1200 1200 to 1500

Getting the proper amount of calcium in the diet every day and participating in weight-bearing exercise (walking, dancing, bicycling, aerobics, jogging), especially during the early years of life (up to about 35 years of age) is most important in helping to build and maintain bones as dense as possible to prevent the development of osteoporosis in later life.

The following table includes some calcium-rich foods. The calcium content of these foods can supply the daily RDA or RNI for calcium if the foods are eaten regularly in sufficient amounts.

Food (amount) Milligrams (mg) of calcium Nonfat dry milk, reconstituted (1 cup) 375 Lowfat, skim, or whole milk (1 cup) 290 to 300 Yogurt (1 cup) 275 to 400 Sardines with bones (3 ounces) 370 Ricotta cheese, part skim (? cup) 340 Salmon, canned, with bones (3 ounces) 285 Cheese, Swiss (1 ounce) 272 Cheese, cheddar (1 ounce) 204 Cheese, American (1 ounce) 174 Cottage cheese, lowfat (1 cup) 154 Tofu (4 ounces) 154 Shrimp (1 cup) 147 Ice milk (? cup) 132

Vitamin D helps prevent calcium loss from your bones. It is sometimes called "the sunshine vitamin" because it is made in your skin when you are exposed to sunlight. If you get outside in the sunlight every day for 15 to 30 minutes, you should get all the vitamin D you need. However, in northern locations in winter, the sunlight may be too weak to make vitamin D in the skin. Vitamin D may also be obtained from your diet or from multivitamin preparations. Most milk is fortified with vitamin D.

Do not use bonemeal or dolomite as a source of calcium. The Food and Drug Administration has issued warnings that bonemeal and dolomite could be dangerous because these products may contain lead.

Before Using This Medicine

If you are taking a dietary supplement without a prescription, carefully read and follow any precautions on the label. For these supplements, the following should be considered:

Allergies

Tell your doctor if you have ever had any unusual or allergic reaction to medicines in this group or any other medicines. Also tell your health care professional if you have any other types of allergies, such as to foods dyes, preservatives, or animals. For non-prescription products, read the label or package ingredients carefully.

Pediatric

Problems in children have not been reported with intake of normal daily recommended amounts. Injectable forms of calcium should not be given to children because of the risk of irritating the injection site.

Geriatric

Problems in older adults have not been reported with intake of normal daily recommended amounts. It is important that older people continue to receive enough calcium in their daily diets. However, some older people may need to take extra calcium or larger doses because they do not absorb calcium as well as younger people. Check with your health care professional if you have any questions about the amount of calcium you should be taking in each day.

Pregnancy

It is especially important that you are receiving enough calcium when you become pregnant and that you continue to receive the right amount of calcium throughout your pregnancy. The healthy growth and development of the fetus depend on a steady supply of nutrients from the mother. However, taking large amounts of a dietary supplement during pregnancy may be harmful to the mother and/or fetus and should be avoided.

Breast Feeding

It is especially important that you receive the right amount of calcium so that your baby will also get the calcium needed to grow properly. However, taking large amounts of a dietary supplement while breast-feeding may be harmful to the mother and/or baby and should be avoided.

Interactions with Medicines

Although certain medicines should not be used together at all, in other cases two different medicines may be used together even if an interaction might occur. In these cases, your doctor may want to change the dose, or other precautions may be necessary. When you are taking any of these dietary supplements, it is especially important that your healthcare professional know if you are taking any of the medicines listed below. The following interactions have been selected on the basis of their potential significance and are not necessarily all-inclusive.

Using dietary supplements in this class with any of the following medicines is usually not recommended, but may be required in some cases. If both medicines are prescribed together, your doctor may change the dose or how often you use one or both of the medicines.

Altretamine Amygdalin Deferoxamine Digoxin Eltrombopag Levomethadyl Licorice Mycophenolate Mofetil Mycophenolic Acid Quinine Rilpivirine Interactions with Food/Tobacco/Alcohol

Certain medicines should not be used at or around the time of eating food or eating certain types of food since interactions may occur. Using alcohol or tobacco with certain medicines may also cause interactions to occur. Discuss with your healthcare professional the use of your medicine with food, alcohol, or tobacco.

Other Medical Problems

The presence of other medical problems may affect the use of dietary supplements in this class. Make sure you tell your doctor if you have any other medical problems, especially:

Diarrhea or Stomach or intestinal problems—Extra calcium or specific calcium preparations may be necessary in these conditions. Heart disease—Calcium by injection may increase the chance of irregular heartbeat. Hypercalcemia (too much calcium in the blood) or Hypercalciuria (too much calcium in the urine)—Calcium supplements may make these conditions worse. Hyperparathyroidism or Sarcoidosis—Calcium supplements may increase the chance of hypercalcemia (too much calcium in the blood). Hypoparathyroidism—Use of calcium phosphate may cause high blood levels of phosphorus which could increase the chance of side effects. Kidney disease or stones—Too much calcium may increase the chance of kidney stones. Proper Use of This Medicine

Drink a full glass (8 ounces) of water or juice when taking a calcium supplement. However, if you are taking calcium carbonate as a phosphate binder in kidney dialysis, it is not necessary to drink a glass of water.

This dietary supplement is best taken 1 to 1? hours after meals, unless otherwise directed by your health care professional. However, patients with a condition known as achlorhydria may not absorb calcium supplements on an empty stomach and should take them with meals.

For individuals taking the chewable tablet form of this dietary supplement:

Chew the tablets completely before swallowing.

For individuals taking the syrup form of this dietary supplement:

Take the syrup before meals. This will allow the dietary supplement to work faster. Mix in water or fruit juice for infants or children.

Take this dietary supplement only as directed. Do not take more of it and do not take it more often than recommended on the label. To do so may increase the chance of side effects.

Dosing

The dose medicines in this class will be different for different patients. Follow your doctor's orders or the directions on the label. The following information includes only the average doses of these medicines. If your dose is different, do not change it unless your doctor tells you to do so.

The amount of medicine that you take depends on the strength of the medicine. Also, the number of doses you take each day, the time allowed between doses, and the length of time you take the medicine depend on the medical problem for which you are using the medicine.

For oral dosage form (capsules, chewable tablets, lozenges, oral solution, oral suspension, syrup, tablets, extended-release tablets, tablets for solution): To prevent deficiency, the amount taken by mouth is based on normal daily recommended intakes (Note that the normal daily recommended intakes are expressed as an actual amount of calcium. The salt form [e.g., calcium carbonate, calcium gluconate, etc.] has a different strength): For the U.S. Adults and teenagers—800 to 1200 milligrams (mg) per day. Pregnant and breast-feeding females—1200 mg per day. Children 4 to 10 years of age—800 mg per day. Children birth to 3 years of age—400 to 800 mg per day. For Canada Adults and teenagers—800 to 1100 mg per day. Adult and teenage females—700 to 1100 mg per day. Pregnant and breast-feeding females—1200 to 1500 mg per day. Children 7 to 10 years of age—700 to 1100 mg per day. Children 4 to 6 years of age—600 mg per day. Children birth to 3 years of age—250 to 550 mg per day. To treat deficiency: Adults, teenagers, and children—Treatment dose is determined by prescriber for each individual based on severity of deficiency. Missed Dose

If you miss a dose of this medicine, take it as soon as possible. However, if it is almost time for your next dose, skip the missed dose and go back to your regular dosing schedule. Do not double doses.

Storage

Keep out of the reach of children.

Store the medicine in a closed container at room temperature, away from heat, moisture, and direct light. Keep from freezing.

Do not keep outdated medicine or medicine no longer needed.

Precautions While Using This Medicine

If this dietary supplement has been ordered for you by your health care professional and you will be taking it in large doses or for a long time, your health care professional should check your progress at regular visits. This is to make sure the calcium is working properly and does not cause unwanted effects.

Do not take calcium supplements within 1 to 2 hours of taking other medicine by mouth. To do so may keep the other medicine from working properly.

Unless you are otherwise directed by your health care professional, to make sure that calcium is used properly by your body:

Do not take other medicines or dietary supplements containing large amounts of calcium, phosphates, magnesium, or vitamin D unless your health care professional has told you to do so or approved. Do not take calcium supplements within 1 to 2 hours of eating large amounts of fiber-containing foods, such as bran and whole-grain cereals or breads, especially if you are being treated for hypocalcemia (not enough calcium in your blood). Do not drink large amounts of alcohol or caffeine-containing beverages (usually more than 8 cups of coffee a day), or use tobacco.

Some calcium carbonate tablets have been shown to break up too slowly in the stomach to be properly absorbed into the body. If the calcium carbonate tablets you purchase are not specifically labeled as being "USP," check with your pharmacist. He or she may be able to help you determine which tablets are best.

Side Effects of This Medicine

Along with its needed effects, a medicine may cause some unwanted effects. Although not all of these side effects may occur, if they do occur they may need medical attention.

Although the following side effects occur very rarely when the calcium supplement is taken as recommended, they may be more likely to occur if it is taken in large doses, if it is taken for a long time or if it is taken by patients with kidney disease.

Check with your doctor as soon as possible if any of the following side effects occur:

More common - For injection form only Dizziness flushing and/or sensation of warmth or heat irregular heartbeat nausea or vomiting skin redness, rash, pain, or burning at injection site sweating tingling sensation Rare Difficult or painful urination drowsiness nausea or vomiting (continuing) Early signs of overdose Constipation (severe) dryness of mouth headache (continuing) increased thirst irritability loss of appetite mental depression metallic taste unusual tiredness or weakness Late signs of overdose Confusion drowsiness (severe) high blood pressure increased sensitivity of eyes or skin to light irregular, fast, or slow heartbeat unusually large amount of urine or increased frequency of urination

Other side effects not listed may also occur in some patients. If you notice any other effects, check with your healthcare professional.

Call your doctor for medical advice about side effects. You may report side effects to the FDA at 1-800-FDA-1088.

The information contained in the Thomson Healthcare (Micromedex) products as delivered by Drugs.com is intended as an educational aid only. It is not intended as medical advice for individual conditions or treatment. It is not a substitute for a medical exam, nor does it replace the need for services provided by medical professionals. Talk to your doctor, nurse or pharmacist before taking any prescription or over the counter drugs (including any herbal medicines or supplements) or following any treatment or regimen. Only your doctor, nurse, or pharmacist can provide you with advice on what is safe and effective for you.

The use of the Thomson Healthcare products is at your sole risk. These products are provided "AS IS" and "as available" for use, without warranties of any kind, either express or implied. Thomson Healthcare and Drugs.com make no representation or warranty as to the accuracy, reliability, timeliness, usefulness or completeness of any of the information contained in the products. Additionally, THOMSON HEALTHCARE MAKES NO REPRESENTATION OR WARRANTIES AS TO THE OPINIONS OR OTHER SERVICE OR DATA YOU MAY ACCESS, DOWNLOAD OR USE AS A RESULT OF USE OF THE THOMSON HEALTHCARE PRODUCTS. ALL IMPLIED WARRANTIES OF MERCHANTABILITY AND FITNESS FOR A PARTICULAR PURPOSE OR USE ARE HEREBY EXCLUDED. Thomson Healthcare does not assume any responsibility or risk for your use of the Thomson Healthcare products.


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