CALCIUMSUPPLEMENTS (Systemic)

Some commonly used brand names are:

In the U.S.?

• Alka-Mints ²
• Amitone ²
• Calcarb 600 ²
• Calci-Chew ²
• Calciday 667 ²
• Calcilac ²
• Calci-Mix ²
• Calcionate ⁵
• Calcium 600 ²
• Calglycine ²
• Calphosan ⁹
• Cal-Plus ²
• Caltrate 600 ²
• Caltrate Jr ²
• Chooz ²
• Citracal ⁴
• Citracal Liquitabs ⁴
• Dicarbosil ²
• Gencalc 600 ²
• Liquid-Cal ²
• Liquid Cal-600 ²
• Maalox Antacid Caplets ²
• Mallamint ²
• Neo-Calglucon ⁵
• Nephro-Calci ²
• Os-Cal 500 ²
• Os-Cal 500 Chewable ²
• Oysco ²
• Oysco 500 Chewable ²
• Oyst-Cal 500 ²
• Oystercal 500 ²
• Posture ¹³
• Rolaids Calcium Rich ²
• Titralac ²
• Tums ²
• Tums 500 ²
• Tums E-X ²

In Canada?

• Apo-Cal ²
• Calciject ³
• Calcite 500 ²
• Calcium-Sandoz ⁵
• Calcium-Sandoz Forte ¹¹
• Calcium Stanley ⁷
• Calsan ²
• Caltrate 600 ²
• Gramcal ¹¹
• Nu-Cal ²
• Os-Cal ²
• Os-Cal Chewable ²
• Tums Extra Strength ²
• Tums Regular Strength ²

Category

• Antacid?Calcium Carbonate
• Antihyperkalemic?Calcium Chloride; Calcium Gluconate Injection
• Antihypermagnesemic?Calcium Chloride; Calcium Gluceptate; Calcium Gluconate Injection
• Antihyperphosphatemic?Calcium Carbonate; Calcium Citrate
• Antihypocalcemic?Calcium Acetate; Calcium Carbonate; Calcium Chloride; CalciumCitrate; Calcium Glubionate; Calcium Gluceptate; Calcium Gluconate; Calcium Glycerophosphateand Calcium Lactate; Calcium Lactate; Calcium Lactate-Gluconate and Calcium Carbonate; Calcium Phosphate, Dibasic; Calcium Phosphate, Tribasic
• Cardiotonic?Calcium Chloride; Calcium Gluconate Injection
• Electrolytereplenisher?Calcium Acetate; Calcium Chloride; CalciumGluceptate; Calcium Gluconate Injection
• Nutritional supplement, mineral?Calcium Carbonate; Calcium Citrate; Calcium Glubionate, Oral; Calcium Gluceptate and Calcium Gluconate; Calcium Gluconate, Oral; Calcium Lactate; CalciumLactate-Gluconate and Calcium Carbonate; Calcium Phosphate, Dibasic; Calcium Phosphate,Tribasic

Description

Calcium supplements are taken by individuals who are unableto 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 workproperly.

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

Pregnant women, nursing mothers, children, and adolescents may need morecalcium than they normally get from eating calcium-rich foods. Adult womenmay take calcium supplements to help prevent a bone disease called osteoporosis.Osteoporosis, which causes thin, porous, easily broken bones, may occur inwomen after menopause, but may sometimes occur in elderly men also. Osteoporosisin women past menopause is thought to be caused by a reduced amount of ovarianestrogen (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 determinedby your health care professional.

Injectable calcium is administered only by or under the supervision ofyour health care professional. Other forms of calcium are available withouta prescription.

Calcium supplements are available in the following dosage forms:

Oral
• Calcium Carbonate
  • Capsules (U.S. and Canada)
  • Oral suspension (U.S.)
  • Tablets (U.S. and Canada)
  • Chewable tablets (U.S. and Canada)
• Calcium Citrate
  • Tablets (U.S.)
  • Tablets for solution (U.S.)
• Calcium Glubionate
  • Syrup (U.S. and Canada)
• Calcium Gluceptate and Calcium Gluconate
  • Oral solution (Canada)
• Calcium Gluconate
  • Tablets (U.S. and Canada)
  • Chewable tablets (U.S.)
• Calcium Lactate
  • Tablets (U.S. and Canada)
• Calcium Lactate-Gluconate and Calcium Carbonate
  • Tablets for solution (Canada)
• Dibasic Calcium Phosphate
  • Tablets (U.S.)
• Tribasic Calcium Phosphate
  • Tablets (U.S.)

Parenteral
• Calcium Acetate
  • Injection (U.S.)
• Calcium Chloride
  • Injection (U.S. and Canada)
• Calcium Glubionate
  • Injection (Canada)
• Calcium Gluceptate
  • Injection (U.S.)
• Calcium Gluconate
  • Injection (U.S. and Canada)
• Calcium Glycerophosphate and Calcium Lactate
  • Injection (U.S.)

A calcium ``salt'' contains calcium along with another substance, suchas carbonate or gluconate. Some calcium salts have more calcium (elementalcalcium) than others. For example, the amount of calcium in calcium carbonateis greater than that in calcium gluconate. To give you an idea of how differentcalcium supplements vary in calcium content, the following chart explainshow many tablets of each type of supplement will provide 1000 milligrams ofelemental calcium. When you look for a calcium supplement, be sure the numberof milligrams on the label refers to the amount of elemental calcium, andnot to the strength of each tablet.

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

Importance of Diet

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

For U.S.?
• Recommended Dietary Allowances (RDAs) are the amount of vitaminsand 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 physicalcondition (e.g., pregnancy).
• Daily Values (DVs) are used on food and dietary supplement labelsto indicate the percent of the recommended daily amount of each nutrient thata serving provides. DV replaces the previous designation of United StatesRecommended Daily Allowances (USRDAs).

For Canada?
• Recommended Nutrient Intakes (RNIs) are used to determine the amountsof vitamins, minerals, and protein needed to provide adequate nutrition andlessen the risk of chronic disease.

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

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

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

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

Food (amount)	Milligrams of calcium
Nonfat dry milk, reconstituted(1 cup)	375
Lowfat, skim, or whole milk (1 cup)	290 to 300
Yogurt (1 cup)	275to 400
Sardines with bones(3 ounces)	370
Ricotta cheese, part skim (1/2 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 (3/4 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 exposedto 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 locationsin winter, the sunlight may be too weak to make vitamin D in the skin. VitaminD may also be obtained from your diet or from multivitamin preparations. Mostmilk 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 bonemealand dolomite could be dangerous because these products may contain lead.

Before Using This Dietary Supplement

If you are taking this dietary supplement without a prescription, carefullyread and follow any precautions on the label. For calcium supplements, thefollowing should be considered:

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

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

Children?Problems in children have not been reported withintake of normal daily recommended amounts. Injectable forms of calcium shouldnot be given to children because of the risk of irritating the injection site.

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

Medicines or other dietary supplements?Although certain medicines or dietary supplements should not be used togetherat all, in other cases they may be used together even if an interaction mightoccur. In these cases, your health care professional may want to change thedose, or other precautions may be necessary. When you are taking calcium supplements,it is especially important that your health care professional know if youare taking any of the following:

• Calcium-containing medicines, other?Taking excess calcium maycause too much calcium in the blood or urine and lead to medical problems

• Cellulose sodium phosphate (e.g., Calcibind)?Use with calciumsupplements may decrease the effects of cellulose sodium phosphate

• Digitalis glycosides (heart medicine)?Use with calcium supplementsby injection may increase the chance of irregular heartbeat

• Etidronate (e.g., Didronel)?Use with calcium supplements maydecrease the effects of etidronate; etidronate should not be taken within2 hours of calcium supplements

• Gallium nitrate (e.g., Ganite)?Use with calcium supplementsmay cause gallium nitrate to not work properly

• Magnesium sulfate (for injection)?Use with calcium supplementsmay cause either medicine to be less effective

• Phenytoin (e.g., Dilantin)?Use with calcium supplements maydecrease the effects of both medicines; calcium supplements should not betaken within 1 to 3 hours of phenytoin

• Tetracyclines (medicine for infection) taken by mouth?Use withcalcium supplements may decrease the effects of tetracycline; calcium supplementsshould not be taken within 1 to 3 hours of tetracyclines

Other medical problems?The presence of other medicalproblems may affect the use of calcium supplements. Make sure you tell yourhealth care professional if you have any other medical problems, especially:

• Diarrhea or
• Stomach or intestinal problems?Extra calcium or specific calciumpreparations may be necessary in these conditions

• Heart disease?Calcium by injection may increase the chanceof irregular heartbeat

• Hypercalcemia (too much calcium in the blood) or
• Hypercalciuria (too much calcium in the urine)?Calcium supplementsmay make these conditions worse

• Hyperparathyroidism or
• Sarcoidosis?Calcium supplements may increase the chance ofhypercalcemia (too much calcium in the blood)

• Hypoparathyroidism?Use of calcium phosphate may cause highblood levels of phosphorus which could increase the chance of side effects

• Kidney disease or stones?Too much calcium may increase thechance of kidney stones

Proper Use of This Dietary Supplement

Dosing?The amount of calcium needed to meet normaldaily recommended intakes will be different for different individuals. Thefollowing information includes only the average amounts of calcium.

• For oral dosage form (capsules, chewabletablets, lozenges, oral solution, oral suspension, syrup, tablets, extended-releasetablets, tablets for solution):
  • To prevent deficiency, the amount taken by mouth is based on normaldaily recommended intakes (Note that the normal daily recommended intakesare expressed as an actual amount of calcium. The salt form [e.g., calciumcarbonate, 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
    • Adult and teenage males?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 determinedby prescriber for each individual based on severity of deficiency.

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 kidneydialysis, it is not necessary to drink a glass of water.

This dietary supplement is best taken 1 to 11/2hours after meals, unless otherwise directed by your health care professional.However, patients with a condition known as achlorhydria may not absorb calciumsupplements on an empty stomach and should take them with meals.

For individuals taking the chewable tablet formof this dietary supplement:

• Chew the tablets completely before swallowing.

For individuals taking the syrup form of thisdietary supplement:

• Take the syrup before meals. This will allow the dietary supplementto 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 anddo not take it more often than recommended on the label. To do so may increasethe chance of side effects.

Missed dose?If you are taking this dietary supplement on aregular schedule and you miss a dose, take it as soon as possible, then goback to your regular dosing schedule.

Storage?To store this dietary supplement:

• Keep out of the reach of children.
• Store away from heat and direct light.
• Do not store in the bathroom, near the kitchen sink, or in otherdamp places. Heat or moisture may cause the dietary supplement to break down.
• Keep the liquid form of this dietary supplement from freezing.
• Do not keep outdated dietary supplements or those no longer needed.Be sure that any discarded dietary supplement is out of the reach of children.

Precautions While Using This Dietary Supplement

If this dietary supplement has been ordered for you by your health careprofessional 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 unwantedeffects.

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

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

• Do not take other medicines or dietary supplementscontaining large amounts of calcium, phosphates, magnesium, or vitamin D unlessyour health care professional has told you to do so or approved.
• Do not take calcium supplements within 1 to 2hours of eating large amounts of fiber-containing foods, such as bran andwhole-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-containingbeverages (usually more than 8 cups of coffee a day), or use tobacco.

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

Side Effects of This Dietary Supplement

Along with its needed effects, a dietary supplement may cause some unwantedeffects. Although the following side effects occur very rarely when the calciumsupplement is taken as recommended, they may be more likely to occur if:

• It is taken in large doses.
• It is taken for a long time.
• It is taken by patients with kidney disease.

Check with your health care professional assoon as possible if any of the following side effects occur:

More common (for injection form only)

Dizziness; flushing and/or sensationof 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); weakness

Early signs of overdose

Constipation (severe) ; dryness of mouth ; headache (continuing) ; increased thirst ; irritability ; loss of appetite ; mental depression ; metallic taste ; unusual tiredness orweakness

Late signs of overdose

Confusion ; drowsiness (severe) ; high blood pressure ; increased sensitivityof eyes or skin to light ; irregular, fast, or slowheartbeat; unusually large amount of urine or increasedfrequency of urination

Other side effects not listed above may also occur in some patients. Ifyou notice any other effects, check with your health care professional.

Additional Information

Once a medicine or dietary supplementhas been approved for marketing for a certain use, experience may show thatit is also useful for other medical problems. Although this use is not includedin product labeling, calcium supplements are used in certain patients withthe following medical condition:

• Hyperphosphatemia (too much phosphate in the blood)

Other than the above information, there is no additional information relatingto proper use, precautions, or side effects for this use.