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    Iron Salts

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    Apr.11.2024

    Iron Salts

    Indications/Dosage

    Labeled

    • anemia
    • anemia of prematurity
    • iron-deficiency anemia
    • nutritional supplementation

    Elemental Iron Content:

    NOTE: Different iron formulations are not directly exchangeable on a mg per mg basis; the different salts contain roughly the following amounts of elemental iron:

    Iron Formulation-(% elemental iron)

    Ferrochel (ferrous bis-glycinate chelate): 75% elemental iron

    Ferrous sulfate-(20% elemental iron)

    Ferrous sulfate, exsiccated (dried)-(30% elemental iron)

    Ferrous gluconate- (12% elemental iron)

    Ferrous fumarate-(33% elemental iron)

    Carbonyl iron -(100% elemental iron)

    Polysaccharide-iron complex- (100% elemental iron) (see Polysaccharide-iron complex monograph).

    Off-Label

      † Off-label indication

      NOTE: Dosage is expressed as elemental iron.[52044]

      Oral dosage

      Adult Males

      8 mg/day PO.[52044]

      Adult Females 51 years and older

      8 mg/day PO.[52044]

      Adult Females 19 to 50 years

      18 mg/day PO.[52044]

      Pregnant Persons

      27 mg/day PO.[52044]

      Lactating Adults

      9 mg/day PO.[52044]

      Lactating Adolescents

      10 mg/day PO.[52044]

      Adolescent Males 14 to 17 years

      11 mg/day PO.[52044] [53377]

      Adolescent Females 14 to 17 years

      15 mg/day PO.[52044]

      Children and Adolescents 9 to 13 years

      8 mg/day PO.[52044]

      Children 4 to 8 years

      10 mg/day PO.[52044]

      Children 1 to 3 years

      7 mg/day PO.[52044] [53377]

      Infants 7 to 11 months

      11 mg/day PO.[52044] [53377] 1 mg/kg/day PO is recommended in breast-fed infants 4 months and older until appropriate iron-containing complementary foods are introduced.[53377]

      Infants 4 to 6 months

      0.27 mg/day PO is the recommended Adequate Intake. No RDA has been established.[52044] [53377] 1 mg/kg/day PO is recommended in breast-fed infants 4 months and older until appropriate iron-containing complementary foods are introduced.[53377]

      Infants 1 to 3 months

      0.27 mg/day PO is the recommended Adequate Intake. No RDA has been established.[52044]

      Term Neonates

      0.27 mg/day PO is the recommended Adequate Intake. No RDA has been established.[52044]

      For the treatment of iron-deficiency anemia

      Oral dosage

      Adults

      60 mg elemental iron PO 1 to 3 times daily for 4 weeks [53763] [54997]. Repeat anemia screening. An increase in hemoglobin of 1 g/dL or more or an increase in hematocrit of 3% or more confirms the diagnosis of iron deficiency anemia. If iron deficiency anemia is confirmed, continue iron treatment for another 2 to 3 months, then repeat anemia screening. Repeat anemia screening again 6 months after successful treatment is completed.[53763] Smaller dosages may be used if GI intolerance occurs; however, correction of the deficiency will occur at a slower rate.[54997]

      Adolescents

      60 mg elemental iron PO 1 to 3 times daily for 4 weeks [53763] [54997]. Repeat anemia screening. An increase in hemoglobin of 1 g/dL or more or an increase in hematocrit of 3% or more confirms the diagnosis of iron deficiency anemia. If iron deficiency anemia is confirmed, continue iron treatment for another 2 to 3 months, then repeat anemia screening. Repeat anemia screening again 6 months after successful treatment is completed.[53763] Smaller dosages may be used if GI intolerance occurs; however, correction of the deficiency will occur at a slower rate.[54997]

      Infants and Children

      3 to 6 mg elemental iron/kg/day PO in 1 to 3 divided doses for 4 weeks. In school-aged children, a dose of 60 mg elemental iron/day has also been recommended. Repeat anemia screening. An increase in hemoglobin of 1 g/dL or more or an increase in hematocrit of 3% or more confirms the diagnosis of iron-deficiency anemia. If iron deficiency anemia is confirmed, continue iron treatment for another 2 to 3 months, then repeat anemia screening. Repeat anemia screening again 6 months after successful treatment is completed.[53761] [53763]

      Term Neonates

      3 to 6 mg elemental iron/kg/day PO in 1 to 3 divided doses for 4 weeks. Repeat anemia screening. An increase in hemoglobin of 1 g/dL or more or an increase in hematocrit of 3% or more confirms the diagnosis of iron-deficiency anemia. If iron deficiency anemia is confirmed, continue iron treatment for another 2 to 3 months then repeat anemia screening. Repeat anemia screening again 6 months after successful treatment is completed.[53761] [53763]

      For anemia of prematurity

      for the prevention of anemia of prematurity

      Oral dosage

      Premature Neonates

      Usual initial dose is 2 to 4 mg elemental iron/kg/day PO.[53456] If erythropoietin alfa is used, doses up to 6 mg elemental iron/kg/day is needed as active erythropoiesis requires additional iron. Begin supplementation between age 2 and 8 weeks and continue for 12 months; starting supplementation at 2 weeks of life may reduce the risk of anemia between age 2 and 6 months. Preterm infants on iron-fortified specialized formula for preterm infants do not require additional iron supplementation.[53456] [53496] NOTE: Prior to administering iron drops, verify the concentration on the bottle; multiple concentrations are available.

      for the treatment of anemia of prematurity

      Oral dosage

      Premature Neonates

      3 to 6 mg elemental iron/kg/day PO for 3 months.[53456] If erythropoietin alfa is used, up to 6 mg elemental iron/kg/day is needed as active erythropoiesis requires additional iron.[53496] NOTE: Prior to administering iron drops, verify the concentration on the bottle; multiple concentrations are available.

      Therapeutic Drug Monitoring

      • Serum iron, hemoglobin and hematocrit should be evaluated prior to iron therapy and at regular intervals during therapy. Ferritin, transferrin, total iron binding capacity, and percent saturation of transferrin are also recommended monitoring parameters.[53226]
      • A response (with improvements in hemoglobin concentration) to oral iron supplementation is typically evident within 1 month of treatment. If such a response is not seen, assessment for nonadherence (due to side effects or other reasons), malabsorption, or ongoing blood loss exceeding iron intake is needed.[66094]

      Maximum Dosage Limits

        Patients with Hepatic Impairment Dosing

        Patients with hepatic disease should receive iron supplementation with caution and only under the direction of a health care prescriber. The liver is one of the main storage sites for iron, and some patients with chronic liver disease may have excessive iron storage. Specific guidelines for dosage adjustments in hepatic impairment are not available.

        Patients with Renal Impairment Dosing

        Specific guidelines for dosage adjustments in renal impairment are not available; it appears that no dosage adjustments are needed.

         

        Intermittent hemodialysis

        Before supplementing hemodialysis patients with iron, a diagnosis of absolute or functional iron deficiency should be made. Follow normal recommended doses; it appears that no dosage adjustments are needed. Iron supplements are not hemodialyzable.

        † Off-label indication
        Revision Date: 04/11/2024, 01:57:00 AM

        References

        52044 - Institute of Medicine, Food and Nutrition Board. Dietary Reference Intakes for Vitamin A, Vitamin K, Arsenic, Boron, Chromium, Copper, Iodine,Iron, Manganese, Molybdenum, Nickel, Silicon, Vanadium, and Zinc. National Academy Press, Washington, DC, 2001.53226 - National Kidney Foundation. NKF-DOQI clinical practice guidelines for the treatment of anemia of chronic renal failure. Available at: http://www.kidney.org/professional/kdoqi/guidelines_updates/koqiupan_iii.html#8. Accessed February 20, 2013.53377 - Baker RD, Greer FR and THE COMMITTEE ON NUTRITION. Clinical Report-Diagnosis and prevention of iron deficiency and iron-deficiency anemia in infants and young children (0-3 years of age). Pediatrics 2010;126:00053456 - Rao R and Georgieff MK. Iron therapy for preterm infants. Clin Perinatol 2009;36:27-42.53496 - Kleinman RE. Nutritional Needs of the Preterm Infant. In: Pediatric Nutrition Handbook. 6th ed. Elk Grove Village, Il: American Academy of Pediatrics;2009:79-112.53761 - American Academy of Pediatrics Committee on Nutrition: Iron Pediatric Nutrition Handbook. 6th ed. Elk Grove Village, Il: American Academy of Pediatrics 2009: pp 403-422.53763 - Centers for Disease Control. Recommendations to Prevent and Control Iron Deficiency in the United States. MMWR 1998;47(RR-3):1-36.54997 - Massey AC. Microcytic anemia Differential diagnosis and management of iron deficiency anemia. Med Clin N Am 1992;76:549-566.66094 - Ko CW, Siddique SM, Patel A, et al. AGA Clinical Practice Guidelines on the Gastrointestinal Evaluation of Iron Deficiency Anemia. Gastroenterology 2020;159:1085-1094.

        How Supplied

        Calcium, Iron Oral tablet

        Iron Sulfate 65mg Enteric-Coated Tablet (35046-0000) (Windmill Health Products, LLC) null

        Calcium, Iron Oral tablet

        Nature Made Iron 65mg Tablet (31604-0042) (Pharmavite, LLC) null

        Ferrous Sulfate Oral tablet

        Iron 65mg Tablet (null) (Mason Vitamins) (off market)

        Iron Chewable tablet

        Ferretts Iron 18mg Supplement Chewable Tablet (00813-0712) (Pharmics Inc) null

        Iron Oral drops, solution

        Iron 15mg/mL Drops (39328-0557) (Patrin Pharma Inc) null

        Iron Oral drops, solution

        ED-In-Sol 75mg/0.6mL Drops (00485-0062) (ITF Pharma formerly Edwards Pharmaceuticals Inc) (off market)

        Iron Oral drops, solution

        Fer-Gen-Sol Drops (00182-1381) (Teva Pharmaceuticals USA) (off market)

        Iron Oral drops, solution

        Fer-In-Sol 15mg/0.6mL Drops (00087-0740) (Mead Johnson ) (off market)

        Iron Oral drops, solution

        Fer-In-Sol 15mg/1mL Drops (00087-0740) (Mead Johnson ) nullFer-In-Sol 15mg/1mL Drops package photo

        Iron Oral drops, solution

        Fer-iron 15mg/0.6mL Drops (00536-0710) (Rugby Laboratories a Division of The Harvard Drug Group, LLC) (off market)

        Iron Oral drops, solution

        Fer-iron 15mg/mL Drops (00536-0710) (Rugby Laboratories a Division of The Harvard Drug Group, LLC) (off market)

        Iron Oral drops, solution

        Ferrous Sulfate 15mg/0.6mL Drops (00904-0989) (Major Pharmaceuticals Inc, a Harvard Drug Group Company) (off market)

        Iron Oral drops, solution

        Ferrous Sulfate 15mg/1mL Drops (00536-1154) (Rugby Laboratories a Division of The Harvard Drug Group, LLC ) (off market)

        Iron Oral drops, solution

        Ferrous Sulfate 75mg/0.6mL Drops (50383-0630) (Hi-Tech Pharmacal, a subsidiary of Akorn) (off market)

        Iron Oral drops, solution

        Ferrous Sulfate 75mg/0.6mL Drops (60432-0057) (Morton Grove Pharmaceuticals Inc, a subsidiary of Wockhardt, Ltd.) (off market)

        Iron Oral drops, solution

        Ferrous Sulfate 75mg/0.6mL Drops (54838-0002) (Silarx Pharmaceuticals Inc) (off market)

        Iron Oral drops, solution

        Ferrous Sulfate 75mg/0.6mL Solution (00426-8057) (Morton Grove Pharmaceuticals Inc, a subsidiary of Wockhardt, Ltd.) (off market)

        Iron Oral drops, solution

        Ferrous Sulfate 75mg/0.6mL Solution (00603-0762) (Par Pharmaceuticals, an Endo Company) (off market)

        Iron Oral drops, solution

        Ferrous Sulfate 75mg/0.6mL Solution (00364-1146) (Teva/Actavis US) (off market)

        Iron Oral drops, solution

        Ferrous Sulfate 75mg/0.6mL Solution (00472-1469) (Teva/Actavis US) (off market)

        Iron Oral drops, solution

        Ferrous Sulfate 75mg/1ml (Elemental Iron 15mg/mL) Drops (00904-6060) (Major Pharmaceuticals Inc, a Harvard Drug Group Company) (off market)

        Iron Oral drops, solution

        Ferrous Sulfate 75mg/1mL (Elemental Iron 15mg/mL) Drops (00904-6060) (Major Pharmaceuticals Inc, a Harvard Drug Group Company) (off market)

        Iron Oral drops, solution

        Ferrous Sulfate 75mg/1mL Drops (50383-0627) (Hi-Tech Pharmacal, a subsidiary of Akorn) (off market)

        Iron Oral drops, solution

        Ferrous Sulfate 75mg/1mL Drops (54838-0002) (Silarx Pharmaceuticals Inc) (off market)

        Iron Oral drops, solution

        Ferrous Sulfate 75mg/1mL Drops (54838-0011) (Silarx Pharmaceuticals Inc) null

        Iron Oral drops, solution

        Infant and Toddler Iron 15mg/mL Drops (00536-1344) (Rugby Laboratories a Division of The Harvard Drug Group, LLC) nullInfant and Toddler Iron 15mg/mL Drops package photo

        Iron Oral drops, solution

        Iron 15mg/1mL Drops (39328-0057) (Patrin Pharma Inc) null

        Iron Oral drops, solution

        Leader Infant & Toddler Iron 15mg/mL Drops (Cherry) (null) (Cardinal Health, Inc.) null

        Iron Oral drops, solution

        Pedia Iron 15mg/mL Drops (76518-0060) (Bayshore Pharmaceuticals) null

        Iron Oral drops, solution

        Pediatric FE-VITE 15mg/1mL Drops (Fruit) (71399-7480) (Akron Pharma Inc.) null

        Iron Oral drops, solution

        Reliable-1 FERROUS SULFATE 15mg/1mL Drops (null) (Reliable 1 Laboratories LLC) nullReliable-1 FERROUS SULFATE 15mg/1mL Drops package photo

        Iron Oral solution

        Fer-iron Liquid (00536-0710) (Rugby Laboratories a Division of The Harvard Drug Group, LLC) (off market)

        Iron Oral solution

        Ferretts IPS 40mg/15mL Solution (00813-2004) (Pharmics Inc) null

        Iron Oral solution

        Ferrous Sulfate 15mg/mL Solution (17856-0627) (Atlantic Biological Corps) null

        Iron Oral solution

        Ferrous Sulfate 300 (60 Fe) mg/6.8mL Solution (69339-0154) (Natco Pharma USA LLC) null

        Iron Oral solution

        Ferrous Sulfate 300mg/5mL Solution (58526-0005) (American Health Packaging) null

        Iron Oral solution

        Ferrous Sulfate 300mg/5mL Solution (50268-0336) (AvPAK; a Division of AvKARE Inc) null

        Iron Oral solution

        Ferrous Sulfate 300mg/5mL Solution (00054-8281) (Hikma Pharmaceuticals USA Inc.) (off market)

        Iron Oral solution

        Ferrous Sulfate 300mg/5mL Solution (00904-7277) (Major Pharmaceuticals Inc, a Harvard Drug Group Company) null

        Iron Oral solution

        Ferrous Sulfate 300mg/5mL Solution (63739-0157) (McKesson Packaging) null

        Iron Oral solution

        Ferrous Sulfate 300mg/5mL Solution (39328-0157) (Patrin Pharma Inc) null

        Iron Oral solution

        Ferrous Sulfate 300mg/5mL Solution (00121-0530) (Pharmaceutical Associates Inc.) null

        Iron Oral solution

        Ferrous Sulfate 300mg/5mL Solution (57237-0311) (Rising Health, LLC) null

        Iron Oral suspension

        ICAR 15mg/1.25mL Pediatric Suspension (63717-0102) (Hawthorn Pharmaceuticals a wholly-owned subsidiary of Currax Pharmaceuticals, LLC) null

        Iron Oral suspension

        MyKidz Iron 10 Suspension (27808-0022) (Tris Pharma, Inc.) (off market)

        Iron Oral suspension

        Wee Care 15mg/1.25mL Pediatric Suspension (Wild Cherry) (23359-0012) (Centurion Labs LLC) null

        Iron Oral tablet

        Radiance Platinum Iron 18mg Tablet (null) (CVS Health) null

        Description/Classification

        Description

        Iron salts are used in the treatment and prevention of iron-deficiency anemia and for nutritional supplementation when iron intake in the diet is inadequate to meet body needs. Iron is an essential mineral and is a component of hemoglobin, myoglobin, and multiple enzymes. The anemia of iron deficiency may result in fatigue, exertional shortness of breath, tachycardia, pallor, headache, glossitis, koilonychia (spoon nails), and decreased cognitive functioning. Meat, fish, and poultry are excellent sources of iron in the diet. Other good dietary sources of iron include beans, dried fruits (e.g., raisins), and enriched cereals and grains. Infant formulas are commonly fortified with iron in the US. Several therapeutic iron salts are available as supplements, including ferrous sulfate, ferrous gluconate, and ferrous fumarate. Some clinicians believe oral ferrous gluconate causes fewer adverse GI effects than does oral ferrous sulfate; however, this observation may be related to the lower amount of elemental iron in ferrous gluconate (12%) relative to ferrous sulfate (20%). Carbonyl iron is a form of elemental iron produced by a chemical carbonyl decomposition process. Carbonyl iron particles are small (e.g., 5 microns) and have large surface areas, which results in improved bioavailability relative to the iron salts. Ferrous sulfate was in use before 1938 and approved by the FDA at its inception.

        Classifications

        • Blood and Blood Forming Organs
          • Anti-anemic Agents
            • Iron Supplements Plain and in Combination
              • Iron Supplements
        • Vitamins, Minerals, and Dietary or Nutritional Supplements
          • Vitamin and Mineral Supplements
            • Iron Supplements (new)
              • Oral Iron Supplements
        Revision Date: 04/11/2024, 01:57:00 AM

        References

        Administration Information

        General Administration Information

        For storage information, see the specific product information within the How Supplied section.

         

        NOTE: Serum iron, hemoglobin and hematocrit should be evaluated prior to iron therapy and at regular intervals during therapy. Serum ferritin and transferrin-saturation may also be helpful monitoring parameters in some patients.

        Route-Specific Administration

        Oral Administration

        • For better absorption, administer 1 hour before or 2 hours after meals. If GI irritation occurs, give with meals. Avoid administering antacids, coffee, tea, dairy products, eggs, or whole grain breads within 1 hour before or 2 hours after giving iron salts.

        Oral Solid Formulations

        • Tablets and capsules: Administer with a full glass of water or juice. Enteric-coated tablets should not be crushed or chewed and capsules should not be opened.

        Oral Liquid Formulations

        • Solutions: May cause temporary staining of the teeth. May be diluted in water or fruit juice and administered with a straw to lessen contact with the tooth enamel. Do not mix in dairy milk.
        • Iron drops: May cause temporary staining of the teeth. Drops may be diluted in infant formula for ease of administration. Do not mix in dairy milk. NOTE: Prior to giving ferrous sulfate drops, verify the concentration on the bottle; two concentrations are available: 15 mg elemental iron/1 mL and 15 mg elemental iron/0.6 mL.

        Clinical Pharmaceutics Information

        From Trissel's 2‚Ñ¢ Clinical Pharmaceutics Database
        Revision Date: 04/11/2024, 01:57:00 AMCopyright 2004-2024 by Lawrence A. Trissel. All Rights Reserved.

        References

        Adverse Reactions

        Mild

        • abdominal pain
        • anorexia
        • diarrhea
        • dyspepsia
        • nausea
        • stool discoloration
        • tooth discoloration
        • vomiting

        Severe

        • acute generalized exanthematous pustulosis (AGEP)
        • esophageal stricture
        • esophageal ulceration
        • odynophagia

        Moderate

        • constipation
        • dysphagia
        • esophagitis
        • hemosiderosis
        • oral ulceration

        Adverse GI effects are common after oral administration of iron salts. Adverse effects can diminish with use and may be reduced by taking iron immediately after meals for a few days, even though this can reduce total iron absorption. Smaller, more frequent doses also can help. The most common adverse GI effects are constipation, abdominal pain, dyspepsia, stool discoloration, nausea, and vomiting. Although infrequent, GI irritation may be severe enough to cause anorexia or diarrhea in some patients.[57505]

        Liquid preparations of iron salts can produce tooth discoloration, a superficial and temporary staining of tooth enamel. Iron can bind to tooth surfaces on contact, or may collect in plaque or etchings on tooth surfaces, thereby causing discoloration. The iron solutions may impart a grey color to the affected teeth. Diluting oral iron liquids with water or fruit juice and drinking the solutions through a straw will help minimize contact of the solutions with the enamel of the teeth. Proper oral hygiene can prevent or remove staining, as can brushing with baking-soda. Iron tablets and capsules do not stain the teeth.[57506]

        Solid oral iron dosage forms may produce local oral ulceration, or esophagitis or esophageal ulceration, respectively, if held within the mouth or lodged within the larynx or esophagus. Iron-induced esophagitis is characterized by sudden onset odynophagia, retrosternal pain, and dysphagia. Other severe complications such as esophageal stricture, bleeding, and perforation have been reported. Risk factors for iron-induced esophageal effects include taking the medication without water and at night. Symptoms usually resolve within days to weeks after stopping the medication. The accidental inhalation of solid iron dosage forms into the lungs has been reported to cause bronchial ulceration and necrosis. These rare events can produce significant morbidity.[57507] [57505]

        Iron is not easily eliminated from the body and acute overdose may result in toxicity. Serum iron levels greater than 300 mcg/dl are potentially toxic. Elevated ferritin levels or transferrin oversaturation may also indicate iron poisoning. The clinical course of acute iron overdosage can be variable. Initial symptoms may include abdominal pain, nausea, vomiting, diarrhea, tarry stools, melena, hematemesis, hypotension, tachycardia, metabolic acidosis, hyperglycemia, dehydration, drowsiness, pallor, cyanosis, lassitude, seizures, shock and coma. Iron overload, which can occur after long-term use of iron, may cause exogenous hemosiderosis. Hemosiderosis is the result of deposition of hemosiderin, an iron-containing pigment, in the tissues of the liver and spleen. Hemosiderosis is rare with proper iron use; periodic monitoring of serum ferritin levels may be helpful in recognizing a progressive accumulation of iron resulting from impaired iron uptake from the reticuloendothelial system. Excessive chronic iron ingestion rarely, if ever, causes hemochromatosis unless a genetic predisposition to the disorder is also present (roughly <= 0.5% of the population). Hemochromatosis results in aberrations of iron metabolism and storage; iron accumulates in the body and excess iron deposition (hemosiderosis) occurs in the parenchymal tissues. With hemochromatosis, the liver becomes enlarged, and skin discoloration, specifically a bronze hue, occurs. Pancreatic dysfunction, diabetes mellitus, cardiac failure, liver failure and other tissue disorders may occur secondary to hemochromatosis.[57508]

        Ferrous fumarate, an iron salt, has been associated with acute generalized exanthematous pustulosis (AGEP). The nonfollicular, pustular, erythematous rash starts suddenly, is associated with fever above 38 degrees C, and is distinct from pustular psoriasis, although biopsy results in each reveal spongiform subcorneal pustules. Drugs are the main cause of AGEP. A period of 2—3 weeks after an inciting drug exposure appears necessary for a first episode of AGEP. Unintentional reexposure may cause a second episode within 2 days. Clinical presentation is diverse with cutaneous lesions beyond erythema and pustules present in half of the cases. For example, bullous lesions, edema, purpura, pruritus, and mucosal erosions are possible. The mean duration of the pustules is 9.7 days followed by an annular desquamation, as long as the causative drug or factor is discontinued. The physiopathological mechanisms of AGEP have not been determined but the pathological criteria of edema, leukocytoclastic vasculitis, eosinophil exocytosis, and keratinocyte focal necrosis are distinctive. Pustule confluence or very small pustules may lead a clinician to make an incorrect diagnosis of TEN, of drug-induced erythroderma, or of staphylococcal scalded skin syndrome.[27736]

        Revision Date: 04/11/2024, 01:57:00 AM

        References

        27736 - Beylot C, Doutre M, Beylot-Barry M. Acute generalized exanthematous pustulosis. Semin Cutan Med Surg 1996;15(4):244-249.57505 - Ferrous gluconate tablet package insert. Minneapolis, MN: Paddock Laboratories, Inc.; 2012 Aug.57506 - Stangel I, et al. Absorption of iron by dentin: its role in discoloration. J Biomed Mater Res. 1996;31:287-292.57507 - Serck-Hanssen A, et al. Esophageal lesions induced by iron tablets. Tidsskr Nor Laegeforen. 1994;114:2129-2131.57508 - Singhi SC, et al. Acute iron poisoning: clinical picture, intensive care needs and outcome. Indian Pediatr. 2003;40:1177-1182.

        Contraindications/Precautions

        Absolute contraindications are italicized.

        • hemochromatosis
        • hemosiderosis
        • sideroblastic anemia
        • thalassemia
        • accidental exposure
        • anemia
        • breast-feeding
        • children
        • colitis
        • dysphagia
        • GI disease
        • GI obstruction
        • hemolytic anemia
        • hepatic disease
        • ileus
        • infants
        • inflammatory bowel disease
        • neonates
        • peptic ulcer disease
        • porphyria
        • pregnancy
        • sulfite hypersensitivity

        Iron salts are only useful for those anemia types where iron-deficiency co-exists. The type of anemia and the underlying cause or causes should be determined before starting therapy with iron. Unnecessary administration of iron salts may lead to iron overload and iron toxicity. Since anemia may be a result of a systemic disturbance, such as recurrent blood loss, the underlying cause(s) should be corrected, if possible. Exogenous Iron salts are only useful for those anemia types where iron-deficiency co-exists. The type of anemia and the underlying cause or causes should be determined before starting therapy with iron. Unnecessary administration of iron salts may lead to iron overload and iron toxicity. Since anemia may be a result of a systemic disturbance, such as recurrent blood loss, the underlying cause(s) should be corrected, if possible. Exogenous administration of iron salts will not alleviate hemolytic anemia and should only be administered to patients with hemolysis if an iron-deficiency is also present. Iron supplementation should be used cautiously in patients receiving blood transfusions because iron overload may occur.

        Administration of iron salts to premature neonates can increase the risk of developing hemolytic anemia because these neonates may have a low vitamin E serum concentration. In general, iron supplementation should not begin until adequate vitamin E is supplied in the diet; human breast milk and modern infant formulas usually supply adequate dietary vitamin E.

        Infants and children should receive iron salts only under the advice and supervision of a qualified health care professional. Accidental exposure to excessive amounts of iron-containing products (i.e., overdose) is the leading cause of fatal poisoning in children under the age of 6 years. Products that contain 30 milligrams (mg) or more of iron per dosage unit are packaged as individual unit-doses. This is to limit the number of pills or capsules a small child could accidentally consume once the package is opened. The FDA published the final rule on the packaging of iron in the January 15, 1997 Federal Register. Under U.S. Consumer Product Safety Commission regulations, most drugs and dietary supplements with more than 250 mg of iron per container must have child-resistant packages. Always store any iron-containing products out of the reach of children and pets. In the case of accidental exposure by ingestion, call a physician or poison control center immediately.

        Those suffering from hereditary/genetic hemochromatosis or hemochromatosis due to secondary iron overload (e.g., as in iron-loading anemias such as thalassemia or sideroblastic anemia) need to avoid iron salts and other iron supplements. Hemochromatosis causes the body to lose its ability to regulate the amount of iron that is absorbed, leading to excess iron absorption and tissue storage. Massive deposition of iron (hemosiderosis) in parenchymal tissues in these conditions may damage the liver, heart, pancreas and other tissues. Porphyria cutanea tarda (PCT) is sometimes associated with parenchymal iron deposits; patients with PCT should avoid iron supplements unless prescribed by a physician. Excess iron supplementation in patients with PCT can contribute to hepatic uroporphinogen decarboxylase deficiency, but the mechanism is not clear. Some patients with chronic hepatic disease may have hemochromatosis or moderate iron overload in hepatic tissues. The liver is one of the main storage sites for iron, and advanced chronic liver disease may result in excess storage iron in the liver. Thus patients with hepatic disease should receive iron supplementation with caution and only under the direction of a health care prescriber.

        Orally administered iron salts may have a corrosive effect that may exacerbate the symptoms associated with certain GI disease states such as peptic ulcer disease or inflammatory bowel disease (e.g., ulcerative colitis). Patients with dysphagia have, on rare occasions, developed oral or esophageal ulcerations from difficulty in swallowing solid oral iron dosage forms. Iron salts may produce constipation and should be used with care in patients with GI obstruction or ileus. Iron products may cause false-positive results on stool guaiac tests for blood.

        When ingested in amounts according to the recommended daily allowances (RDA), iron salts are considered safe for use during pregnancy. Routine iron supplementation during pregnancy appears to prevent low maternal hemoglobin at birth and in the immediate postpartum period. The effect of routine iron supplementation on fetal or maternal outcomes is not clear, but is thought to be beneficial. Pregnant women should supplement iron salts during pregnancy only when advised to do so by a qualified health care professional.[52044] [62528]

        Use of iron supplements within the recommended daily dietary intake for lactating women is generally recognized as safe.[49822] While iron is excreted into breast-milk, the iron content of breast milk is not readily affected by the iron content of the maternal diet or the maternal serum iron level.[49626] Therefore, the use of iron salts, under the direction of a health care prescriber, is compatible with breast-feeding if the lactating mother needs treatment for iron deficiency. Consider the benefits of breast-feeding, the risk of potential infant drug exposure, and the risk of an untreated or inadequately treated condition. If a breast-feeding infant experiences an adverse effect related to a maternally ingested drug, healthcare providers are encouraged to report the adverse effect to the FDA.

        Some iron products contain sulfites and should be used with caution in patients with a known sulfite hypersensitivity. Although the overall prevalence of sulfite hypersensitivity is low, it is seen more frequently in asthmatics or in atopic non-asthmatic persons.

        Revision Date: 04/11/2024, 01:57:00 AM

        References

        49626 - Griffin IJ, Abrams SA. Iron and breastfeeding. Pediatr Clin North Am 2001;48:401-13.49822 - National Research Council. "Nutrient Supplementation." Nutrition During Pregnancy and Lactation: An Implementation Guide. Washington, DC: The National Academies Press, 1992.52044 - Institute of Medicine, Food and Nutrition Board. Dietary Reference Intakes for Vitamin A, Vitamin K, Arsenic, Boron, Chromium, Copper, Iodine,Iron, Manganese, Molybdenum, Nickel, Silicon, Vanadium, and Zinc. National Academy Press, Washington, DC, 2001.62528 - Burke RM, Leon JS, Suchdev PS. Identification, prevention and treatment of iron deficiency during the first 1000 days. Nutrients 2014;6:4093-4114.

        Mechanism of Action

        Normal erythropoiesis is dependent on the concentration of iron and erythropoietin available in the plasma. Approximately two-thirds of total body iron is in the circulating red blood cell mass as hemoglobin, the major factor in oxygen transport. Administration of iron does not stimulate the production of red blood cells, nor does it correct abnormalities not caused by iron deficiency. A therapeutic response to treatment with iron products is dependent on the patient's ability to absorb and use the iron. The response to iron therapy is also influenced by the cause of the deficiency as well as other illnesses that can affect normal erythropoiesis. A positive response to iron treatment can be noted by an increase in the reticulocyte count within 1 week of therapy and an increase in hemoglobin at roughly 3—4 weeks, assuming that transfusion or other interventions cannot explain the improvements in the patients clinical status.

         

        Iron-containing proteins and enzymes are important in oxidation-reduction reactions, especially those of the mitochondria. Iron is a component of myoglobin and several heme-enzymes, including the cytochromes, catalase, and peroxidase. Iron is an essential component of the metalloflavoprotein enzymes and the mitochondrial enzyme alpha-glycerophosphate oxidase. Furthermore, iron is a cofactor for enzymes such as aconitase and tryptophan pyrrolase. Iron deficiency not only causes anemia and decreased oxygen delivery, it also reduces the metabolism of muscle and decreases mitochondrial activity. Iron deficiency can also lead to defects in learning or thermoregulation. Thus iron is important to several metabolic functions which are independent of its importance to erythropoiesis.

        Revision Date: 04/11/2024, 01:57:00 AM

        References

        Pharmacokinetics

        Iron salts are administered orally. Once absorbed, the amount of total body iron content is used to form essential iron-dependent compounds and any excess iron is stored. Most of the essential iron in the body is contained in hemoglobin. Roughly 80% of plasma iron goes to the bone marrow to produce new erythrocytes. Other iron-dependent essential compounds include myoglobin and iron-dependent enzymes. The internal transport of iron to essential sites depends on the plasma protein transferrin. Transferrin delivers iron to specific transferrin receptors at target tissues, which then deliver iron to intracellular sites. Transferrin is extruded from the cell once iron is delivered intracellularly. The production of transferrin receptors is regulated according to body needs; when iron is deficient, transferrin receptors increase and iron storage via ferritin decreases. Ferritin is the storage protein for iron. The main sites of iron storage are the liver, spleen, bone marrow, and the reticuloendothelial system; a minor portion is stored in the muscle. After a life-cycle of roughly 120 days, roughly 0.8%/day of the circulating erythrocytes are catabolized by the reticuloendothelial system (RES); at that time, some of the iron is recirculated to the plasma bound to transferrin. The remaining iron from erythrocyte breakdown is incorporated into ferritin stores in the RES and hepatocytes. The utilization of iron by the body is designed to maintain body stores, so very little physiologic loss of iron occurs once it is in the body. In healthy adults, daily loss of iron occurs primarily through GI losses (e.g., bile, exfoliated mucosal or red cells); minor amounts are lost through skin desquamation or the urine. Physiologic losses in adult males average roughly 1 mg/day. Iron status will determine the magnitude of iron loss; less iron is lost in those individuals with iron deficiency. Those patients with excessive iron intake may lose up to 2 mg/day.

        Route-Specific Pharmacokinetics

        Oral Route

        When iron is taken orally, the acidic environment of the stomach maintains iron in its more soluble ferrous (and more readily absorbed) state. Iron is then absorbed through the duodenum and upper small intestines. Although orally administered iron is absorbed in the duodenum, iron directly instilled into the duodenum is poorly absorbed.[23689] Intraduodenal pH is much higher than intragastric pH due to the high concentration of pancreatic secretions in the duodenum. Both ascorbic acid and meat (heme iron) will increase the absorption of non-heme iron. A hematopoietic transcription factor, known as NF-E2, regulates the absorption of iron by the oral route in response to erythropoiesis. Increased oral uptake into the systemic circulation occurs when iron deficiency or increased erythropoiesis (e.g., epoetin alfa therapy) is present. When iron stores are adequate, less iron is absorbed across the intestinal mucosa. The absorptive process across the intestine is finite, limiting the amount of entry of iron into the systemic circulation on a daily basis, even in deficiency. Oral iron absorption rarely exceeds 2 mg/day.

        Special Populations

        Hepatic Impairment

        Some patients with chronic liver disease may exhibit excessive iron storage; use with caution in this population.

        Renal Impairment

        Iron is not hemodialyzable.

        Pediatrics

        The hematopoietic systems of the fetus in utero and the neonate are complex. Premature infants are borne with defective erythropoiesis and without adequate iron storage and may develop a condition known as anemia of prematurity. Thus, premature infants generally have increased iron requirements relative to term infants. Term infants have adequate iron stores from birth to roughly age 6 months; after that time iron needs must be met by the diet.

        Gender Differences

        Men have roughly twice the body iron stores compared to women. Menstruating women have an increased loss of iron as compared to adult males, as do other persons with loss of blood. Pregnancy increases iron-intake requirements.

        Other

        Patients with partial gastrectomy or with malabsorption syndromes will have impaired absorption of iron from food. 

        Revision Date: 04/11/2024, 01:57:00 AM

        References

        23689 - Rhodes J, Beton D, Brown DA. Absorption of iron instilled into the stomach, duodenum, and jejunum. Gut 1968;9:323-4.

        Pregnancy/Breast-feeding

        pregnancy

        When ingested in amounts according to the recommended daily allowances (RDA), iron salts are considered safe for use during pregnancy. Routine iron supplementation during pregnancy appears to prevent low maternal hemoglobin at birth and in the immediate postpartum period. The effect of routine iron supplementation on fetal or maternal outcomes is not clear, but is thought to be beneficial. Pregnant women should supplement iron salts during pregnancy only when advised to do so by a qualified health care professional.[52044] [62528]

        breast-feeding

        Use of iron supplements within the recommended daily dietary intake for lactating women is generally recognized as safe.[49822] While iron is excreted into breast-milk, the iron content of breast milk is not readily affected by the iron content of the maternal diet or the maternal serum iron level.[49626] Therefore, the use of iron salts, under the direction of a health care prescriber, is compatible with breast-feeding if the lactating mother needs treatment for iron deficiency. Consider the benefits of breast-feeding, the risk of potential infant drug exposure, and the risk of an untreated or inadequately treated condition. If a breast-feeding infant experiences an adverse effect related to a maternally ingested drug, healthcare providers are encouraged to report the adverse effect to the FDA.

        Revision Date: 04/11/2024, 01:57:00 AM

        References

        49626 - Griffin IJ, Abrams SA. Iron and breastfeeding. Pediatr Clin North Am 2001;48:401-13.49822 - National Research Council. "Nutrient Supplementation." Nutrition During Pregnancy and Lactation: An Implementation Guide. Washington, DC: The National Academies Press, 1992.52044 - Institute of Medicine, Food and Nutrition Board. Dietary Reference Intakes for Vitamin A, Vitamin K, Arsenic, Boron, Chromium, Copper, Iodine,Iron, Manganese, Molybdenum, Nickel, Silicon, Vanadium, and Zinc. National Academy Press, Washington, DC, 2001.62528 - Burke RM, Leon JS, Suchdev PS. Identification, prevention and treatment of iron deficiency during the first 1000 days. Nutrients 2014;6:4093-4114.

        Interactions

        Level 2 (Major)

        • Baloxavir Marboxil
        • Delafloxacin
        • Dimercaprol
        • Edetate Calcium Disodium, Calcium EDTA
        • Eltrombopag
        • Estramustine
        • Ethotoin
        • Ferric carboxymaltose
        • Ferric Derisomaltose
        • Ferumoxytol
        • food
        • Gemifloxacin
        • Green Tea
        • Iron - Injectable Only
        • Iron Dextran
        • Iron Sucrose, Sucroferric Oxyhydroxide
        • Lanthanum Carbonate
        • Magnesium Sulfate; Potassium Sulfate; Sodium Sulfate
        • Methyldopa
        • Moxifloxacin
        • Penicillamine
        • Polyethylene Glycol; Electrolytes
        • Polyethylene Glycol; Electrolytes; Ascorbic Acid
        • Sulfacetamide; Sulfur
        • Trientine

        Level 3 (Moderate)

        • Abacavir; Dolutegravir; Lamivudine
        • Acetohydroxamic Acid
        • Alendronate
        • Alendronate; Cholecalciferol
        • Aliskiren; Hydrochlorothiazide, HCTZ
        • Aluminum Hydroxide
        • Aluminum Hydroxide; Magnesium Carbonate
        • Aluminum Hydroxide; Magnesium Hydroxide
        • Aluminum Hydroxide; Magnesium Hydroxide; Simethicone
        • Aluminum Hydroxide; Magnesium Trisilicate
        • Amiloride; Hydrochlorothiazide, HCTZ
        • Amlodipine; Valsartan; Hydrochlorothiazide, HCTZ
        • Amoxicillin; Clarithromycin; Omeprazole
        • Antacids
        • Aspirin, ASA; Citric Acid; Sodium Bicarbonate
        • Aspirin, ASA; Omeprazole
        • Atenolol; Chlorthalidone
        • Atracurium
        • Azilsartan; Chlorthalidone
        • Benazepril; Hydrochlorothiazide, HCTZ
        • Bictegravir; Emtricitabine; Tenofovir Alafenamide
        • Bismuth Subcitrate Potassium; Metronidazole; Tetracycline
        • Bismuth Subsalicylate; Metronidazole; Tetracycline
        • Bisoprolol; Hydrochlorothiazide, HCTZ
        • Cabotegravir
        • Cabotegravir; Rilpivirine
        • Calcifediol
        • Calcitonin
        • Calcitriol
        • Calcium Carbonate
        • Calcium Carbonate; Famotidine; Magnesium Hydroxide
        • Calcium Carbonate; Magnesium Hydroxide
        • Calcium Carbonate; Magnesium Hydroxide; Simethicone
        • Calcium Carbonate; Simethicone
        • Calcium Phosphate, Supersaturated
        • Calcium; Vitamin D
        • Candesartan; Hydrochlorothiazide, HCTZ
        • Captopril; Hydrochlorothiazide, HCTZ
        • Carbidopa; Levodopa
        • Carbidopa; Levodopa; Entacapone
        • Cardiac glycosides
        • Cefdinir
        • Chlorothiazide
        • Chlorpheniramine; Pseudoephedrine
        • Chlorthalidone
        • Cholestyramine
        • Ciprofloxacin
        • Cisatracurium
        • Demeclocycline
        • Dexlansoprazole
        • Didanosine, ddI
        • Digoxin
        • Dolutegravir
        • Dolutegravir; Lamivudine
        • Dolutegravir; Rilpivirine
        • Doxercalciferol
        • Doxycycline
        • Elvitegravir; Cobicistat; Emtricitabine; Tenofovir Alafenamide
        • Elvitegravir; Cobicistat; Emtricitabine; Tenofovir Disoproxil Fumarate
        • Enalapril; Hydrochlorothiazide, HCTZ
        • Eprosartan; Hydrochlorothiazide, HCTZ
        • Esomeprazole
        • Etidronate
        • Fosinopril; Hydrochlorothiazide, HCTZ
        • Hydrochlorothiazide, HCTZ
        • Hydrochlorothiazide, HCTZ; Moexipril
        • Ibandronate
        • Ibritumomab Tiuxetan
        • Irbesartan; Hydrochlorothiazide, HCTZ
        • Lansoprazole
        • Lansoprazole; Amoxicillin; Clarithromycin
        • Levodopa
        • Levofloxacin
        • Levothyroxine
        • Levothyroxine; Liothyronine (Porcine)
        • Levothyroxine; Liothyronine (Synthetic)
        • Liothyronine
        • Lisinopril; Hydrochlorothiazide, HCTZ
        • Lithium
        • Losartan; Hydrochlorothiazide, HCTZ
        • Magnesium Hydroxide
        • Magnesium Salts
        • Metolazone
        • Metoprolol; Hydrochlorothiazide, HCTZ
        • Minocycline
        • Mycophenolate
        • Naproxen; Esomeprazole
        • Neuromuscular blockers
        • Ofloxacin
        • Olmesartan; Amlodipine; Hydrochlorothiazide, HCTZ
        • Olmesartan; Hydrochlorothiazide, HCTZ
        • Omadacycline
        • Omeprazole
        • Omeprazole; Amoxicillin; Rifabutin
        • Omeprazole; Sodium Bicarbonate
        • Pancuronium
        • Pantoprazole
        • Parathyroid Hormone
        • Paricalcitol
        • Phosphorated Carbohydrate Solution
        • Phosphorus
        • Potassium Phosphate
        • Potassium Phosphate; Sodium Phosphate
        • Proton pump inhibitors
        • Quinapril; Hydrochlorothiazide, HCTZ
        • Rabeprazole
        • Risedronate
        • Rocuronium
        • Sarecycline
        • Sodium Bicarbonate
        • Sodium Fluoride
        • Sodium Phosphate Monobasic Monohydrate; Sodium Phosphate Dibasic Anhydrous
        • Sodium picosulfate; Magnesium oxide; Anhydrous citric acid
        • Spironolactone; Hydrochlorothiazide, HCTZ
        • Succinylcholine
        • Telmisartan; Hydrochlorothiazide, HCTZ
        • Teriparatide
        • Tetracycline
        • Tetracyclines
        • Thiazide diuretics
        • Thyroid hormones
        • Triamterene; Hydrochlorothiazide, HCTZ
        • Valsartan; Hydrochlorothiazide, HCTZ
        • Vecuronium
        • Vitamin D analogs
        • Vonoprazan
        • Vonoprazan; Amoxicillin
        • Vonoprazan; Amoxicillin; Clarithromycin
        • Zinc
        • Zinc Salts

        Level 4 (Minor)

        • Amlodipine
        • Amlodipine; Atorvastatin
        • Amlodipine; Benazepril
        • Amlodipine; Celecoxib
        • Amlodipine; Olmesartan
        • Amlodipine; Valsartan
        • Atenolol
        • Calcipotriene
        • Calcipotriene; Betamethasone
        • Calcium-channel blockers
        • Cimetidine
        • Clevidipine
        • Cod Liver Oil
        • Conjugated Estrogens
        • Conjugated Estrogens; Bazedoxifene
        • Conjugated Estrogens; Medroxyprogesterone
        • Desogestrel; Ethinyl Estradiol
        • Dienogest; Estradiol valerate
        • Diltiazem
        • Drospirenone; Estetrol
        • Drospirenone; Estradiol
        • Drospirenone; Ethinyl Estradiol
        • Drospirenone; Ethinyl Estradiol; Levomefolate
        • Elagolix; Estradiol; Norethindrone acetate
        • enteral feedings
        • Esterified Estrogens
        • Esterified Estrogens; Methyltestosterone
        • Estradiol
        • Estradiol; Levonorgestrel
        • Estradiol; Norethindrone
        • Estradiol; Norgestimate
        • Estradiol; Progesterone
        • Estrogens
        • Estropipate
        • Ethinyl Estradiol; Norelgestromin
        • Ethinyl Estradiol; Norethindrone Acetate
        • Ethinyl Estradiol; Norgestrel
        • Ethynodiol Diacetate; Ethinyl Estradiol
        • Etonogestrel; Ethinyl Estradiol
        • Famotidine
        • Felodipine
        • H2-blockers
        • Ibuprofen; Famotidine
        • Isradipine
        • Levamlodipine
        • Levonorgestrel; Ethinyl Estradiol
        • Levonorgestrel; Ethinyl Estradiol; Ferrous Bisglycinate
        • Levonorgestrel; Ethinyl Estradiol; Ferrous Fumarate
        • Nicardipine
        • NIFEdipine
        • Nimodipine
        • Nisoldipine
        • Nizatidine
        • Norethindrone Acetate; Ethinyl Estradiol; Ferrous fumarate
        • Norethindrone; Ethinyl Estradiol
        • Norethindrone; Ethinyl Estradiol; Ferrous fumarate
        • Norgestimate; Ethinyl Estradiol
        • Perindopril; Amlodipine
        • Ranitidine
        • Relugolix; Estradiol; Norethindrone acetate
        • Segesterone Acetate; Ethinyl Estradiol
        • Telmisartan; Amlodipine
        • Trandolapril; Verapamil
        • Verapamil
        • Vitamin A
        Abacavir; Dolutegravir; Lamivudine: (Moderate) Administer dolutegravir 2 hours before or 6 hours after taking supplements containing calcium if given under fasting conditions. When taken with food, dolutegravir and supplements containing calcium can be taken at the same time. Simultaneous administration under fasted conditions may result in reduced bioavailability of dolutegravir. [55594] (Moderate) Administer dolutegravir 2 hours before or 6 hours after taking supplements containing iron if given under fasting conditions. When taken with food, dolutegravir and supplements containing iron can be taken at the same time. Simultaneous administration under fasted conditions may result in reduced bioavailability of dolutegravir. [55594] Acetohydroxamic Acid: (Moderate) Acetohydroxamic acid chelates heavy metals, including iron. Absorption of orally administered iron salts or polysaccharide-iron complex and acetohydroxamic acid from the intestinal lumen may be reduced when both drugs are administered concomitantly. If iron therapy is required in a patient currently taking acetohydroxamic acid, intramuscular iron is recommended. [41504] Alendronate: (Moderate) Separate administration of alendronate and calcium-containing supplements by at least 30 minutes. Calcium will interfere with the absorption of alendronate. [28644] [52249] (Moderate) Separate administration of alendronate and iron supplements by at least 30 minutes. Iron will interfere with the absorption of alendronate. [28644] [52249] Alendronate; Cholecalciferol: (Moderate) Separate administration of alendronate and calcium-containing supplements by at least 30 minutes. Calcium will interfere with the absorption of alendronate. [28644] [52249] (Moderate) Separate administration of alendronate and iron supplements by at least 30 minutes. Iron will interfere with the absorption of alendronate. [28644] [52249] Aliskiren; Hydrochlorothiazide, HCTZ: (Moderate) Monitor serum calcium concentration during concomitant calcium and thiazide diuretic use due to the risk for hypercalcemia. Thiazide diuretics may decrease urinary calcium excretion and cause intermittent and slight increases in serum calcium. [48850] [63883] Aluminum Hydroxide: (Moderate) Doses of antacids and iron should be taken as far apart as possible to minimize the potential for interaction. Antacids may decrease the absorption of oral iron preparations. At higher pH values, iron is more readily ionized to its ferric state and is more poorly absorbed. [27981] Aluminum Hydroxide; Magnesium Carbonate: (Moderate) Doses of antacids and iron should be taken as far apart as possible to minimize the potential for interaction. Antacids may decrease the absorption of oral iron preparations. At higher pH values, iron is more readily ionized to its ferric state and is more poorly absorbed. [27981] Aluminum Hydroxide; Magnesium Hydroxide: (Moderate) Doses of antacids and iron should be taken as far apart as possible to minimize the potential for interaction. Antacids may decrease the absorption of oral iron preparations. At higher pH values, iron is more readily ionized to its ferric state and is more poorly absorbed. [27981] Aluminum Hydroxide; Magnesium Hydroxide; Simethicone: (Moderate) Doses of antacids and iron should be taken as far apart as possible to minimize the potential for interaction. Antacids may decrease the absorption of oral iron preparations. At higher pH values, iron is more readily ionized to its ferric state and is more poorly absorbed. [27981] Aluminum Hydroxide; Magnesium Trisilicate: (Moderate) Doses of antacids and iron should be taken as far apart as possible to minimize the potential for interaction. Antacids may decrease the absorption of oral iron preparations. At higher pH values, iron is more readily ionized to its ferric state and is more poorly absorbed. [27981] Amiloride; Hydrochlorothiazide, HCTZ: (Moderate) Monitor serum calcium concentration during concomitant calcium and thiazide diuretic use due to the risk for hypercalcemia. Thiazide diuretics may decrease urinary calcium excretion and cause intermittent and slight increases in serum calcium. [48850] [63883] Amlodipine: (Minor) Monitor blood pressure during concurrent use of calcium and calcium-channel blockers. Concomitant use may reduce the response to calcium-channel blockers. [53985] [69004] Amlodipine; Atorvastatin: (Minor) Monitor blood pressure during concurrent use of calcium and calcium-channel blockers. Concomitant use may reduce the response to calcium-channel blockers. [53985] [69004] Amlodipine; Benazepril: (Minor) Monitor blood pressure during concurrent use of calcium and calcium-channel blockers. Concomitant use may reduce the response to calcium-channel blockers. [53985] [69004] Amlodipine; Celecoxib: (Minor) Monitor blood pressure during concurrent use of calcium and calcium-channel blockers. Concomitant use may reduce the response to calcium-channel blockers. [53985] [69004] Amlodipine; Olmesartan: (Minor) Monitor blood pressure during concurrent use of calcium and calcium-channel blockers. Concomitant use may reduce the response to calcium-channel blockers. [53985] [69004] Amlodipine; Valsartan: (Minor) Monitor blood pressure during concurrent use of calcium and calcium-channel blockers. Concomitant use may reduce the response to calcium-channel blockers. [53985] [69004] Amlodipine; Valsartan; Hydrochlorothiazide, HCTZ: (Moderate) Monitor serum calcium concentration during concomitant calcium and thiazide diuretic use due to the risk for hypercalcemia. Thiazide diuretics may decrease urinary calcium excretion and cause intermittent and slight increases in serum calcium. [48850] [63883] (Minor) Monitor blood pressure during concurrent use of calcium and calcium-channel blockers. Concomitant use may reduce the response to calcium-channel blockers. [53985] [69004] Amoxicillin; Clarithromycin; Omeprazole: (Moderate) The bioavailability of oral iron salts is influenced by gastric pH, and the concomitant administration of proton pump inhibitors can decrease iron absorption. The non-heme ferric form of iron needs an acidic intragastric pH to be reduced to ferrous and to be absorbed. Iron salts and polysaccharide-iron complex provide non-heme iron. Proton pump inhibitors have long-lasting effects on the secretion of gastric acid and thus, increase the pH of the stomach. The increase in intragastric pH can interfere with the absorption of iron salts. [29564] [35599] [48854] Antacids: (Moderate) Doses of antacids and iron should be taken as far apart as possible to minimize the potential for interaction. Antacids may decrease the absorption of oral iron preparations. At higher pH values, iron is more readily ionized to its ferric state and is more poorly absorbed. [27981] Aspirin, ASA; Citric Acid; Sodium Bicarbonate: (Moderate) Doses of antacids and iron should be taken as far apart as possible to minimize the potential for interaction. Antacids may decrease the absorption of oral iron preparations. At higher pH values, iron is more readily ionized to its ferric state and is more poorly absorbed. [27981] Aspirin, ASA; Omeprazole: (Moderate) The bioavailability of oral iron salts is influenced by gastric pH, and the concomitant administration of proton pump inhibitors can decrease iron absorption. The non-heme ferric form of iron needs an acidic intragastric pH to be reduced to ferrous and to be absorbed. Iron salts and polysaccharide-iron complex provide non-heme iron. Proton pump inhibitors have long-lasting effects on the secretion of gastric acid and thus, increase the pH of the stomach. The increase in intragastric pH can interfere with the absorption of iron salts. [29564] [35599] [48854] Atenolol: (Minor) Calcium antacids (e.g., calcium carbonate) and supplements (e.g., other oral calcium salts) have been reported to reduce the mean peak concentrations by 51% and the AUC of atenolol by 32%. In another study, antacids reduced the AUC of atenolol by 33%. Separate doses of atenolol and calcium-containing antacids or supplements by at least 2 hours to minimize this potential interaction,. However, most clinicians consider the interaction of atenolol with antacids to be of minor clinical significance, since clinical efficacy (heart rate and blood pressure parameters) appear to be unchanged under usual intermittent clinical use. [4382] [4384] Atenolol; Chlorthalidone: (Moderate) Monitor serum calcium concentration during concomitant calcium and thiazide diuretic use due to the risk for hypercalcemia. Thiazide diuretics may decrease urinary calcium excretion and cause intermittent and slight increases in serum calcium. [48850] [63883] (Minor) Calcium antacids (e.g., calcium carbonate) and supplements (e.g., other oral calcium salts) have been reported to reduce the mean peak concentrations by 51% and the AUC of atenolol by 32%. In another study, antacids reduced the AUC of atenolol by 33%. Separate doses of atenolol and calcium-containing antacids or supplements by at least 2 hours to minimize this potential interaction,. However, most clinicians consider the interaction of atenolol with antacids to be of minor clinical significance, since clinical efficacy (heart rate and blood pressure parameters) appear to be unchanged under usual intermittent clinical use. [4382] [4384] Atracurium: (Moderate) Concomitant use of neuromuscular blockers and calcium may result in resistance to neuromuscular blockade. Calcium antagonizes the potentiating effect of magnesium on neuromuscular blockade. Also, calcium triggers acetylcholine release, and therefore, may both reduce the sensitivity to neuromuscular blockers and decrease the duration of neuromuscular blockade. [65345] Azilsartan; Chlorthalidone: (Moderate) Monitor serum calcium concentration during concomitant calcium and thiazide diuretic use due to the risk for hypercalcemia. Thiazide diuretics may decrease urinary calcium excretion and cause intermittent and slight increases in serum calcium. [48850] [63883] Baloxavir Marboxil: (Major) Avoid concomitant use of baloxavir with oral dietary supplements containing iron. Oral iron interferes with baloxavir absorption and may reduce baloxavir efficacy. In animal studies, polyvalent cations like iron reduced baloxavir overall exposure by 48% to 63%. [63687] (Major) Do not administer baloxavir with products that contain calcium. Polyvalent cations, such as calcium, can chelate with baloxavir, reducing its absorption. [63687] Benazepril; Hydrochlorothiazide, HCTZ: (Moderate) Monitor serum calcium concentration during concomitant calcium and thiazide diuretic use due to the risk for hypercalcemia. Thiazide diuretics may decrease urinary calcium excretion and cause intermittent and slight increases in serum calcium. [48850] [63883] Bictegravir; Emtricitabine; Tenofovir Alafenamide: (Moderate) Administer bictegravir with food at the same time as iron supplements. Routine administration of bictegravir under fasting conditions simultaneously with, or 2 hours after, iron supplements is not recommended. Iron is a polyvalent cation that can bind bictegravir in the GI tract. Taking these drugs simultaneously without food results in reduced bioavailability of bictegravir. In drug interaction studies, simultaneous administration of bictegravir and ferrous fumarate under fasted conditions decreased the mean AUC of bictegravir by approximately 63%. [62852] (Moderate) Administer bictegravir with food at the same time as oral calcium supplements. Routine administration of bictegravir under fasting conditions simultaneously with, or 2 hours after, calcium supplements is not recommended. Calcium is a polyvalent cation that can bind bictegravir in the GI tract. Taking these drugs simultaneously without food results in reduced bioavailability of bictegravir. In drug interaction studies, simultaneous administration of bictegravir with another calcium supplement under fasted conditions decreased the mean AUC of bictegravir by approximately 33%. [62852] Bismuth Subcitrate Potassium; Metronidazole; Tetracycline: (Moderate) Divalent or trivalent cations readily chelate with tetracycline antibiotics, forming insoluble compounds. The oral absorption of these antibiotics will be significantly reduced by other orally administered compounds that contain calcium salts, particularly if the time of administration is within 60 minutes of each other. Calcium salts and tetracyclines should not be administered within 1 to 2 hours of each other, although doxycycline chelates less with calcium than other tetracyclines. [4691] [6707] (Moderate) Separate administration of tetracyclines and iron by 2 to 3 hours. Iron may decrease the oral bioavailability of tetracyclines. [27974] [29959] [64502] [67408] Bismuth Subsalicylate; Metronidazole; Tetracycline: (Moderate) Divalent or trivalent cations readily chelate with tetracycline antibiotics, forming insoluble compounds. The oral absorption of these antibiotics will be significantly reduced by other orally administered compounds that contain calcium salts, particularly if the time of administration is within 60 minutes of each other. Calcium salts and tetracyclines should not be administered within 1 to 2 hours of each other, although doxycycline chelates less with calcium than other tetracyclines. [4691] [6707] (Moderate) Separate administration of tetracyclines and iron by 2 to 3 hours. Iron may decrease the oral bioavailability of tetracyclines. [27974] [29959] [64502] [67408] Bisoprolol; Hydrochlorothiazide, HCTZ: (Moderate) Monitor serum calcium concentration during concomitant calcium and thiazide diuretic use due to the risk for hypercalcemia. Thiazide diuretics may decrease urinary calcium excretion and cause intermittent and slight increases in serum calcium. [48850] [63883] Cabotegravir: (Moderate) Administer oral calcium at least two hours before or four hours after taking oral cabotegravir. Calcium is a polyvalent cation that can bind cabotegravir in the GI tract. Taking these drugs simultaneously may result in reduced oral bioavailability of cabotegravir. [66315] (Moderate) Administer oral iron at least two hours before or four hours after taking oral cabotegravir. Iron is a polyvalent cation that can bind cabotegravir in the GI tract. Taking these drugs simultaneously may result in reduced oral bioavailability of cabotegravir. [66315] Cabotegravir; Rilpivirine: (Moderate) Administer oral calcium at least two hours before or four hours after taking oral cabotegravir. Calcium is a polyvalent cation that can bind cabotegravir in the GI tract. Taking these drugs simultaneously may result in reduced oral bioavailability of cabotegravir. [66315] (Moderate) Administer oral iron at least two hours before or four hours after taking oral cabotegravir. Iron is a polyvalent cation that can bind cabotegravir in the GI tract. Taking these drugs simultaneously may result in reduced oral bioavailability of cabotegravir. [66315] Calcifediol: (Moderate) Monitor serum calcium concentrations during concomitant use of high doses of calcium and vitamin D analogs; a dosage adjustment of the vitamin D analog may be needed. Hypercalcemia may be exacerbated by concomitant administration. [28490] [30153] [60895] Calcipotriene: (Minor) There is evidence that calcipotriene can be absorbed in amounts that are sufficient to produce systemic effects, including elevated serum calcium; hypercalcemia has been observed in normal prescription use. Use calcipotriene cautiously with other agents that can produce hypercalcemia (e.g., calcium salts or supplements including calcium carbonate). [31986] Calcipotriene; Betamethasone: (Minor) There is evidence that calcipotriene can be absorbed in amounts that are sufficient to produce systemic effects, including elevated serum calcium; hypercalcemia has been observed in normal prescription use. Use calcipotriene cautiously with other agents that can produce hypercalcemia (e.g., calcium salts or supplements including calcium carbonate). [31986] Calcitonin: (Moderate) Calcitonin is given to hypercalcemic patients to reduce serum calcium concentrations. For the treatment of hypercalcemia, calcium supplements should be avoided. Calcium salts, including calcium carbonate, can elevate serum calcium concentrations and antagonize the effects of the calcitonin for this condition. For the treatment of osteoporosis adequate intake of calcium salts are necessary in conjunction with calcitonin. An increase in serum calcium concentrations helps to reduce bone resorption and loss of bone mass, and offsets the effect of calcitonin in lowering serum calcium levels. [27980] Calcitriol: (Moderate) Monitor serum calcium concentrations during concomitant use of high doses of calcium and vitamin D analogs; a dosage adjustment of the vitamin D analog may be needed. Hypercalcemia may be exacerbated by concomitant administration. [28490] [30153] [60895] Calcium Carbonate: (Moderate) Antacids (e.g., calcium carbonate, aluminum hydroxide, or magnesium hydroxide) may decrease the absorption of oral iron preparations (e.g., iron salts or polysaccharide-iron complex). At higher pH values, iron is more readily ionized to its ferric state and is more poorly absorbed. Doses of antacids and iron should be taken as far apart as possible to minimize the potential for interaction. [4698] Calcium Carbonate; Famotidine; Magnesium Hydroxide: (Moderate) Antacids (e.g., calcium carbonate, aluminum hydroxide, or magnesium hydroxide) may decrease the absorption of oral iron preparations (e.g., iron salts or polysaccharide-iron complex). At higher pH values, iron is more readily ionized to its ferric state and is more poorly absorbed. Doses of antacids and iron should be taken as far apart as possible to minimize the potential for interaction. [4698] (Minor) The bioavailability of oral iron salts is influenced by gastric pH, and the concomitant administration of H2-blockers can decrease iron absorption. The non-heme ferric form of iron needs an acidic intragastric pH to be reduced to ferrous and to be absorbed. Iron salts and polysaccharide-iron complex provide non-heme iron. H2-blockers have long-lasting effects on the secretion of gastric acid and thus, increase the pH of the stomach. The increase in intragastric pH can interfere with the absorption of iron salts. [6305] Calcium Carbonate; Magnesium Hydroxide: (Moderate) Antacids (e.g., calcium carbonate, aluminum hydroxide, or magnesium hydroxide) may decrease the absorption of oral iron preparations (e.g., iron salts or polysaccharide-iron complex). At higher pH values, iron is more readily ionized to its ferric state and is more poorly absorbed. Doses of antacids and iron should be taken as far apart as possible to minimize the potential for interaction. [4698] Calcium Carbonate; Magnesium Hydroxide; Simethicone: (Moderate) Antacids (e.g., calcium carbonate, aluminum hydroxide, or magnesium hydroxide) may decrease the absorption of oral iron preparations (e.g., iron salts or polysaccharide-iron complex). At higher pH values, iron is more readily ionized to its ferric state and is more poorly absorbed. Doses of antacids and iron should be taken as far apart as possible to minimize the potential for interaction. [4698] Calcium Carbonate; Simethicone: (Moderate) Antacids (e.g., calcium carbonate, aluminum hydroxide, or magnesium hydroxide) may decrease the absorption of oral iron preparations (e.g., iron salts or polysaccharide-iron complex). At higher pH values, iron is more readily ionized to its ferric state and is more poorly absorbed. Doses of antacids and iron should be taken as far apart as possible to minimize the potential for interaction. [4698] Calcium Phosphate, Supersaturated: (Moderate) The concomitant use of oral sodium phosphate monobasic monohydrate; sodium phosphate dibasic anhydrous preparations in conjunction with antacids containing calcium (e.g., calcium carbonate, calcium salts) may bind the phosphate in the stomach and reduce its absorption. If the patient requires multiple mineral supplements or concurrent use of antacids, it is prudent to separate the administration of sodium phosphate salts from calcium containing products by at least one hour. [7800] Calcium; Vitamin D: (Moderate) Antacids (e.g., calcium carbonate, aluminum hydroxide, or magnesium hydroxide) may decrease the absorption of oral iron preparations (e.g., iron salts or polysaccharide-iron complex). At higher pH values, iron is more readily ionized to its ferric state and is more poorly absorbed. Doses of antacids and iron should be taken as far apart as possible to minimize the potential for interaction. [4698] Calcium-channel blockers: (Minor) Monitor blood pressure during concurrent use of calcium and calcium-channel blockers. Concomitant use may reduce the response to calcium-channel blockers. [53985] [69004] Candesartan; Hydrochlorothiazide, HCTZ: (Moderate) Monitor serum calcium concentration during concomitant calcium and thiazide diuretic use due to the risk for hypercalcemia. Thiazide diuretics may decrease urinary calcium excretion and cause intermittent and slight increases in serum calcium. [48850] [63883] Captopril; Hydrochlorothiazide, HCTZ: (Moderate) Monitor serum calcium concentration during concomitant calcium and thiazide diuretic use due to the risk for hypercalcemia. Thiazide diuretics may decrease urinary calcium excretion and cause intermittent and slight increases in serum calcium. [48850] [63883] Carbidopa; Levodopa: (Moderate) Administration of iron salts, including polysaccharide-iron complex or multivitamins containing iron, should be separated from oral levodopa by at least 2 hours to avoid reduction in levodopa efficacy. Iron salts may reduce the bioavailability of levodopa and carbidopa; levodopa products. [48681] [52387] [58735] [58749] [58757] [63854] Carbidopa; Levodopa; Entacapone: (Moderate) Administration of iron salts, including polysaccharide-iron complex or multivitamins containing iron, should be separated from oral levodopa by at least 2 hours to avoid reduction in levodopa efficacy. Iron salts may reduce the bioavailability of levodopa and carbidopa; levodopa products. [48681] [52387] [58735] [58749] [58757] [63854] Cardiac glycosides: (Moderate) Monitor for signs and symptoms of digoxin toxicity during concomitant calcium use. Hypercalcemia may predispose persons to digoxin toxicity. If IV calcium is administered rapidly in a person receiving digoxin, serious arrhythmias may occur. Monitor ECG and calcium concentrations closely during IV calcium and digoxin administration. [28272] [53985] Cefdinir: (Moderate) Administer cefdinir at least 2 hours before or 2 hours after iron supplements. Cefdinir absorption may be reduced. Coadministration of cefdinir with a therapeutic iron supplement containing 60 mg of elemental iron or vitamins supplemented with 10 mg of elemental iron reduced extent of absorption by 80% and 31%, respectively. [29349] [33926] Chlorothiazide: (Moderate) Monitor serum calcium concentration during concomitant calcium and thiazide diuretic use due to the risk for hypercalcemia. Thiazide diuretics may decrease urinary calcium excretion and cause intermittent and slight increases in serum calcium. [48850] [63883] Chlorpheniramine; Pseudoephedrine: (Moderate) Orally administered zinc salts compete with iron supplements for absorption from the intestine. To minimize the interaction, separate oral iron and zinc doses by at least 2 hours. The oral receipt of 100 mg of iron as ferrous gluconate with 12 mg zinc in 11 patients with normal iron status and comparable total exchangeable zinc pools yielded a mean zinc absorption of 26.4% +/- 14.4% of the administered dose as compared with 44.5% +/- 22.5% of the dose given without concomitant iron. Concomitant use of iron 400 mg as ferrous gluconate yielded a mean zinc absorption of 22.9% +/- 6.4% of the zinc dose. [29182] Chlorthalidone: (Moderate) Monitor serum calcium concentration during concomitant calcium and thiazide diuretic use due to the risk for hypercalcemia. Thiazide diuretics may decrease urinary calcium excretion and cause intermittent and slight increases in serum calcium. [48850] [63883] Cholestyramine: (Moderate) Concurrent administration of cholestyramine and oral iron supplements may reduce the oral absorption of iron. To avoid any oral absorption interference, administration of other drugs is recommended 1 hour before or at least 4 to 6 hours after cholestyramine administration. [28070] Cimetidine: (Minor) The bioavailability of oral iron salts is influenced by gastric pH, and the concomitant administration of H2-blockers can decrease iron absorption. The non-heme ferric form of iron needs an acidic intragastric pH to be reduced to ferrous and to be absorbed. Iron salts and polysaccharide-iron complex provide non-heme iron. H2-blockers have long-lasting effects on the secretion of gastric acid and thus, increase the pH of the stomach. The increase in intragastric pH can interfere with the absorption of iron salts. [6305] Ciprofloxacin: (Moderate) Administer oral ciprofloxacin at least 2 hours before or 6 hours after oral products that contain calcium. Ciprofloxacin absorption may be reduced as quinolone antibiotics can chelate with divalent or trivalent cations. Examples of compounds that may interfere with quinolone bioavailability include antacids and multivitamins that contain calcium. [43411] [43570] (Moderate) Administer oral ciprofloxacin at least 2 hours before or 6 hours after oral products that contain iron. Ciprofloxacin absorption may be reduced as quinolone antibiotics can chelate with divalent or trivalent cations. [43411] [43570] [64502] Cisatracurium: (Moderate) Concomitant use of neuromuscular blockers and calcium may result in resistance to neuromuscular blockade. Calcium antagonizes the potentiating effect of magnesium on neuromuscular blockade. Also, calcium triggers acetylcholine release, and therefore, may both reduce the sensitivity to neuromuscular blockers and decrease the duration of neuromuscular blockade. [65345] Clevidipine: (Minor) Monitor blood pressure during concurrent use of calcium and calcium-channel blockers. Concomitant use may reduce the response to calcium-channel blockers. [53985] [69004] Cod Liver Oil: (Minor) Doses in excess of 1,500 to 2,000 mcg per day of Vitamin A may lead to bone loss and will counteract the effects of supplementation with calcium salts. [8242] [8257] Conjugated Estrogens: (Minor) Estrogens can increase calcium absorption. Use caution in patients predisposed to hypercalcemia or nephrolithiasis. [6395] Conjugated Estrogens; Bazedoxifene: (Minor) Estrogens can increase calcium absorption. Use caution in patients predisposed to hypercalcemia or nephrolithiasis. [6395] Conjugated Estrogens; Medroxyprogesterone: (Minor) Estrogens can increase calcium absorption. Use caution in patients predisposed to hypercalcemia or nephrolithiasis. [6395] Delafloxacin: (Major) Administer oral delafloxacin at least 2 hours before or 6 hours after oral products that contain calcium. Delafloxacin absorption may be reduced as quinolone antibiotics can chelate with divalent or trivalent cations. Examples of compounds that may interfere with fluoroquinolone bioavailability include antacids and multivitamins that contain calcium. [62028] (Major) Administer oral delafloxacin at least 2 hours before or 6 hours after oral products that contain iron. Delafloxacin absorption may be reduced as quinolone antibiotics can chelate with divalent or trivalent cations. Examples of compounds that may interfere with quinolone bioavailability include multivitamins that contain iron. [62028] Demeclocycline: (Moderate) Divalent or trivalent cations readily chelate with tetracycline antibiotics, forming insoluble compounds. The oral absorption of these antibiotics will be significantly reduced by other orally administered compounds that contain calcium salts, particularly if the time of administration is within 60 minutes of each other. Calcium salts and tetracyclines should not be administered within 1 to 2 hours of each other, although doxycycline chelates less with calcium than other tetracyclines. [4691] [6707] (Moderate) Separate administration of tetracyclines and iron by 2 to 3 hours. Iron may decrease the oral bioavailability of tetracyclines. [27974] [29959] [64502] [67408] Desogestrel; Ethinyl Estradiol: (Minor) Estrogens can increase calcium absorption. Use caution in patients predisposed to hypercalcemia or nephrolithiasis. [6395] Dexlansoprazole: (Moderate) The bioavailability of oral iron salts is influenced by gastric pH, and the concomitant administration of proton pump inhibitors can decrease iron absorption. The non-heme ferric form of iron needs an acidic intragastric pH to be reduced to ferrous and to be absorbed. Iron salts and polysaccharide-iron complex provide non-heme iron. Proton pump inhibitors have long-lasting effects on the secretion of gastric acid and thus, increase the pH of the stomach. The increase in intragastric pH can interfere with the absorption of iron salts. [29564] [35599] [48854] Didanosine, ddI: (Moderate) Iron salts should not be administered simultaneously with didanosine, ddI chewable tablets or powder for oral solution. Oral absorption of iron supplements is reduced if given with antacids; the buffering agents contained in didanosine tablets and powder likewise reduce iron salt absorption. Administer oral doses of iron salts 1 hour before or 4 hours after didanosine tablet or powder administration. The delayed-release didanosine capsules do not contain a buffering agent and would not be expected to interact with iron salts. [6073] Dienogest; Estradiol valerate: (Minor) Estrogens can increase calcium absorption. Use caution in patients predisposed to hypercalcemia or nephrolithiasis. [6395] Digoxin: (Moderate) Monitor for signs and symptoms of digoxin toxicity during concomitant calcium use. Hypercalcemia may predispose persons to digoxin toxicity. If IV calcium is administered rapidly in a person receiving digoxin, serious arrhythmias may occur. Monitor ECG and calcium concentrations closely during IV calcium and digoxin administration. [28272] [53985] Diltiazem: (Minor) Monitor blood pressure during concurrent use of calcium and calcium-channel blockers. Concomitant use may reduce the response to calcium-channel blockers. [53985] [69004] Dimercaprol: (Major) Avoid concomitant use of dimercaprol and products containing iron. Dimercaprol forms toxic-chelates with iron which increases the risk for nephrotoxicity and other adverse effects. [29902] Dolutegravir: (Moderate) Administer dolutegravir 2 hours before or 6 hours after taking supplements containing calcium if given under fasting conditions. When taken with food, dolutegravir and supplements containing calcium can be taken at the same time. Simultaneous administration under fasted conditions may result in reduced bioavailability of dolutegravir. [55594] (Moderate) Administer dolutegravir 2 hours before or 6 hours after taking supplements containing iron if given under fasting conditions. When taken with food, dolutegravir and supplements containing iron can be taken at the same time. Simultaneous administration under fasted conditions may result in reduced bioavailability of dolutegravir. [55594] Dolutegravir; Lamivudine: (Moderate) Administer dolutegravir 2 hours before or 6 hours after taking supplements containing calcium if given under fasting conditions. When taken with food, dolutegravir and supplements containing calcium can be taken at the same time. Simultaneous administration under fasted conditions may result in reduced bioavailability of dolutegravir. [55594] (Moderate) Administer dolutegravir 2 hours before or 6 hours after taking supplements containing iron if given under fasting conditions. When taken with food, dolutegravir and supplements containing iron can be taken at the same time. Simultaneous administration under fasted conditions may result in reduced bioavailability of dolutegravir. [55594] Dolutegravir; Rilpivirine: (Moderate) Administer dolutegravir 2 hours before or 6 hours after taking supplements containing calcium if given under fasting conditions. When taken with food, dolutegravir and supplements containing calcium can be taken at the same time. Simultaneous administration under fasted conditions may result in reduced bioavailability of dolutegravir. [55594] (Moderate) Administer dolutegravir 2 hours before or 6 hours after taking supplements containing iron if given under fasting conditions. When taken with food, dolutegravir and supplements containing iron can be taken at the same time. Simultaneous administration under fasted conditions may result in reduced bioavailability of dolutegravir. [55594] Doxercalciferol: (Moderate) Monitor serum calcium concentrations during concomitant use of high doses of calcium and vitamin D analogs; a dosage adjustment of the vitamin D analog may be needed. Hypercalcemia may be exacerbated by concomitant administration. [28490] [30153] [60895] Doxycycline: (Moderate) Divalent or trivalent cations readily chelate with tetracycline antibiotics, forming insoluble compounds. The oral absorption of these antibiotics will be significantly reduced by other orally administered compounds that contain calcium salts, particularly if the time of administration is within 60 minutes of each other. Calcium salts and tetracyclines should not be administered within 1 to 2 hours of each other, although doxycycline chelates less with calcium than other tetracyclines. [4691] [6707] (Moderate) Separate administration of tetracyclines and iron by 2 to 3 hours. Iron may decrease the oral bioavailability of tetracyclines. [27974] [29959] [64502] [67408] Drospirenone; Estetrol: (Minor) Estrogens can increase calcium absorption. Use caution in patients predisposed to hypercalcemia or nephrolithiasis. [6395] Drospirenone; Estradiol: (Minor) Estrogens can increase calcium absorption. Use caution in patients predisposed to hypercalcemia or nephrolithiasis. [6395] Drospirenone; Ethinyl Estradiol: (Minor) Estrogens can increase calcium absorption. Use caution in patients predisposed to hypercalcemia or nephrolithiasis. [6395] Drospirenone; Ethinyl Estradiol; Levomefolate: (Minor) Estrogens can increase calcium absorption. Use caution in patients predisposed to hypercalcemia or nephrolithiasis. [6395] Edetate Calcium Disodium, Calcium EDTA: (Major) Because edetate disodium chelates and lowers serum calcium, oral or parenteral calcium salts should not be administered concomitantly. [7090] Elagolix; Estradiol; Norethindrone acetate: (Minor) Estrogens can increase calcium absorption. Use caution in patients predisposed to hypercalcemia or nephrolithiasis. [6395] Eltrombopag: (Major) Eltrombopag chelates polyvalent cations (e.g., calcium, aluminum, and magnesium) in food, mineral supplements, and antacids. In a clinical study, systemic exposure to eltrombopag was decreased by 70% when it was administered with a polyvalent cation-containing antacid. Administer eltrombopag at least 2 hours before or 4 hours after any oral products containing polyvalent cations, such as aluminum salts, (like aluminum hydroxide), calcium salts, (including calcium carbonate), and magnesium salts. [40392] (Major) Eltrombopag chelates polyvalent cations (e.g., iron) in foods and mineral supplements. In a clinical study, systemic exposure to eltrombopag was decreased by 70% when it was administered with a polyvalent cation-containing antacid. Administer eltrombopag at least 2 hours before or 4 hours after any oral products containing polyvalent cations, such as iron salts, multivitamins that contain iron, or polysaccharide-iron complex. [40392] Elvitegravir; Cobicistat; Emtricitabine; Tenofovir Alafenamide: (Moderate) Separate administration of elvitegravir and calcium by at least 2 hours. Due to the formation of ionic complexes in the gastrointestinal tract, simultaneous administration results in lower elvitegravir plasma concentrations. [51664] [58001] (Moderate) Separate administration of elvitegravir and iron by at least 2 hours. Due to the formation of ionic complexes in the gastrointestinal tract, simultaneous administration results in lower elvitegravir plasma concentrations. [51664] [58001] Elvitegravir; Cobicistat; Emtricitabine; Tenofovir Disoproxil Fumarate: (Moderate) Separate administration of elvitegravir and calcium by at least 2 hours. Due to the formation of ionic complexes in the gastrointestinal tract, simultaneous administration results in lower elvitegravir plasma concentrations. [51664] [58001] (Moderate) Separate administration of elvitegravir and iron by at least 2 hours. Due to the formation of ionic complexes in the gastrointestinal tract, simultaneous administration results in lower elvitegravir plasma concentrations. [51664] [58001] Enalapril; Hydrochlorothiazide, HCTZ: (Moderate) Monitor serum calcium concentration during concomitant calcium and thiazide diuretic use due to the risk for hypercalcemia. Thiazide diuretics may decrease urinary calcium excretion and cause intermittent and slight increases in serum calcium. [48850] [63883] Enteral Feedings: (Minor) Ferrous sulfate elixir has an acidic pH and has been reported to form precipitates with enteral feedings and may clog feeding tubes. [6785] [6787] Eprosartan; Hydrochlorothiazide, HCTZ: (Moderate) Monitor serum calcium concentration during concomitant calcium and thiazide diuretic use due to the risk for hypercalcemia. Thiazide diuretics may decrease urinary calcium excretion and cause intermittent and slight increases in serum calcium. [48850] [63883] Esomeprazole: (Moderate) The bioavailability of oral iron salts is influenced by gastric pH, and the concomitant administration of proton pump inhibitors can decrease iron absorption. The non-heme ferric form of iron needs an acidic intragastric pH to be reduced to ferrous and to be absorbed. Iron salts and polysaccharide-iron complex provide non-heme iron. Proton pump inhibitors have long-lasting effects on the secretion of gastric acid and thus, increase the pH of the stomach. The increase in intragastric pH can interfere with the absorption of iron salts. [29564] [35599] [48854] Esterified Estrogens: (Minor) Estrogens can increase calcium absorption. Use caution in patients predisposed to hypercalcemia or nephrolithiasis. [6395] Esterified Estrogens; Methyltestosterone: (Minor) Estrogens can increase calcium absorption. Use caution in patients predisposed to hypercalcemia or nephrolithiasis. [6395] Estradiol: (Minor) Estrogens can increase calcium absorption. Use caution in patients predisposed to hypercalcemia or nephrolithiasis. [6395] Estradiol; Levonorgestrel: (Minor) Estrogens can increase calcium absorption. Use caution in patients predisposed to hypercalcemia or nephrolithiasis. [6395] Estradiol; Norethindrone: (Minor) Estrogens can increase calcium absorption. Use caution in patients predisposed to hypercalcemia or nephrolithiasis. [6395] Estradiol; Norgestimate: (Minor) Estrogens can increase calcium absorption. Use caution in patients predisposed to hypercalcemia or nephrolithiasis. [6395] Estradiol; Progesterone: (Minor) Estrogens can increase calcium absorption. Use caution in patients predisposed to hypercalcemia or nephrolithiasis. [6395] Estramustine: (Major) Administration of estramustine with calcium impairs the oral absorption of estramustine significantly, due to formation of a calcium-phosphate complex. Calcium-containing drugs must not be taken simultaneously with estramustine. Patients should be instructed to take estramustine with water at least 1 hour before or 2 hours after calcium supplements. [47275] Estrogens: (Minor) Estrogens can increase calcium absorption. Use caution in patients predisposed to hypercalcemia or nephrolithiasis. [6395] Estropipate: (Minor) Estrogens can increase calcium absorption. Use caution in patients predisposed to hypercalcemia or nephrolithiasis. [6395] Ethinyl Estradiol; Norelgestromin: (Minor) Estrogens can increase calcium absorption. Use caution in patients predisposed to hypercalcemia or nephrolithiasis. [6395] Ethinyl Estradiol; Norethindrone Acetate: (Minor) Estrogens can increase calcium absorption. Use caution in patients predisposed to hypercalcemia or nephrolithiasis. [6395] Ethinyl Estradiol; Norgestrel: (Minor) Estrogens can increase calcium absorption. Use caution in patients predisposed to hypercalcemia or nephrolithiasis. [6395] Ethotoin: (Major) Oral absorption of phenytoin can be reduced by calcium salts. Calcium salts can form complexes that are nonabsorbable. Separating the administration of phenytoin and calcium salts by at least 2 hours to help avoid this interaction. A similar interaction may occur with ethotoin. [23674] Ethynodiol Diacetate; Ethinyl Estradiol: (Minor) Estrogens can increase calcium absorption. Use caution in patients predisposed to hypercalcemia or nephrolithiasis. [6395] Etidronate: (Moderate) Separate administration of oral etidronate and calcium-containing supplements by at least 2 hours. Calcium will interfere with the absorption of oral etidronate. [28655] (Moderate) Separate administration of oral etidronate and iron supplements by at least 2 hours. Iron will interfere with the absorption of oral etidronate. [28655] Etonogestrel; Ethinyl Estradiol: (Minor) Estrogens can increase calcium absorption. Use caution in patients predisposed to hypercalcemia or nephrolithiasis. [6395] Famotidine: (Minor) The bioavailability of oral iron salts is influenced by gastric pH, and the concomitant administration of H2-blockers can decrease iron absorption. The non-heme ferric form of iron needs an acidic intragastric pH to be reduced to ferrous and to be absorbed. Iron salts and polysaccharide-iron complex provide non-heme iron. H2-blockers have long-lasting effects on the secretion of gastric acid and thus, increase the pH of the stomach. The increase in intragastric pH can interfere with the absorption of iron salts. [6305] Felodipine: (Minor) Monitor blood pressure during concurrent use of calcium and calcium-channel blockers. Concomitant use may reduce the response to calcium-channel blockers. [53985] [69004] Ferric carboxymaltose: (Major) Parenteral iron formulas are generally only indicated for use in patients with documented iron deficiency in whom oral administration is either impossible or unsatisfactory. In general, do not administer parenteral iron concomitantly with other iron preparations (e.g., other parenteral iron products or oral iron supplements). Parenteral iron preparations (e.g., iron dextran; iron sucrose, sucroferric oxyhydroxide; sodium ferric gluconate complex; ferric carboxymaltose; ferumoxytol) may reduce the absorption of concomitantly administered oral iron preparations. Oral iron supplementation should be discontinued before parenteral administration of iron. Too much iron can be toxic, and iron is not easily eliminated from the body. [29895] [42291] Ferric Derisomaltose: (Major) Parenteral iron formulas are generally only indicated for use in patients with documented iron deficiency in whom oral administration is either impossible or unsatisfactory. In general, do not administer parenteral iron concomitantly with other iron preparations (e.g., other parenteral iron products or oral iron supplements). Parenteral iron preparations (e.g., iron dextran; iron sucrose, sucroferric oxyhydroxide; sodium ferric gluconate complex; ferric carboxymaltose; ferumoxytol) may reduce the absorption of concomitantly administered oral iron preparations. Oral iron supplementation should be discontinued before parenteral administration of iron. Too much iron can be toxic, and iron is not easily eliminated from the body. [29895] [42291] Ferumoxytol: (Major) Parenteral iron formulas are generally only indicated for use in patients with documented iron deficiency in whom oral administration is either impossible or unsatisfactory. In general, do not administer parenteral iron concomitantly with other iron preparations (e.g., other parenteral iron products or oral iron supplements). Parenteral iron preparations (e.g., iron dextran; iron sucrose, sucroferric oxyhydroxide; sodium ferric gluconate complex; ferric carboxymaltose; ferumoxytol) may reduce the absorption of concomitantly administered oral iron preparations. Oral iron supplementation should be discontinued before parenteral administration of iron. Too much iron can be toxic, and iron is not easily eliminated from the body. [29895] [42291] Food: (Major) For better iron absorption, administer iron salts 1 hour before or 2 hours after meals. If GI irritation occurs, the iron supplement may be administered with meals. However, where possible, avoid administering coffee, tea, or dairy products within 1 hour before or 2 hours after giving iron. [6732] Fosinopril; Hydrochlorothiazide, HCTZ: (Moderate) Monitor serum calcium concentration during concomitant calcium and thiazide diuretic use due to the risk for hypercalcemia. Thiazide diuretics may decrease urinary calcium excretion and cause intermittent and slight increases in serum calcium. [48850] [63883] Gemifloxacin: (Major) Administer oral products that contain iron at least 3 hours before or 2 hours after gemifloxacin. Gemifloxacin absorption may be reduced as quinolone antibiotics can chelate with divalent or trivalent cations. Examples of compounds that may interfere with quinolone bioavailability include multivitamins that contain iron. [28424] Green Tea: (Major) Green tea has been shown to inhibit the absorption of nonheme iron. When possible, do not consume green tea or green tea extract within 1 hour before or 2 hours after giving iron salts. [6606] H2-blockers: (Minor) The bioavailability of oral iron salts is influenced by gastric pH, and the concomitant administration of H2-blockers can decrease iron absorption. The non-heme ferric form of iron needs an acidic intragastric pH to be reduced to ferrous and to be absorbed. Iron salts and polysaccharide-iron complex provide non-heme iron. H2-blockers have long-lasting effects on the secretion of gastric acid and thus, increase the pH of the stomach. The increase in intragastric pH can interfere with the absorption of iron salts. [6305] Hydrochlorothiazide, HCTZ: (Moderate) Monitor serum calcium concentration during concomitant calcium and thiazide diuretic use due to the risk for hypercalcemia. Thiazide diuretics may decrease urinary calcium excretion and cause intermittent and slight increases in serum calcium. [48850] [63883] Hydrochlorothiazide, HCTZ; Moexipril: (Moderate) Monitor serum calcium concentration during concomitant calcium and thiazide diuretic use due to the risk for hypercalcemia. Thiazide diuretics may decrease urinary calcium excretion and cause intermittent and slight increases in serum calcium. [48850] [63883] Ibandronate: (Moderate) Separate administration of oral ibandronate and calcium-containing supplements by at least 1 hour. Calcium will interfere with the absorption of oral ibandronate. [29558] (Moderate) Separate administration of oral ibandronate and iron supplements by at least 1 hour. Iron will interfere with the absorption of oral ibandronate. [29558] Ibritumomab Tiuxetan: (Moderate) It has been reported that high intakes of phosphates, such as are found in dietary supplements or food additives, can interfere with absorption of trace nutrients such as iron, copper, and zinc. The magnitude of the effect may be small, and the interactions require further study to judge clinical significance. The theorized mechanism is the formation of insoluble complexes within the gut. Until more data are available, it may be helpful to separate administration times of phosphates by as much as possible from the oral administration of iron (e.g., iron salts or polysaccharide-iron complex), copper salts, or zinc salts to limit any potential interactions. [29060] [29985] [30998] [31028] (Moderate) The oral absorption of phosphorus is reduced by ingestion of pharmacologic doses of calcium carbonate or other phosphate-lowering calcium salts (e.g., calcium acetate). There is, however, no significant interference with phosphorus absorption by oral dietary calcium at intakes within the typical adult range. If the patient requires multiple calcium supplements or a calcium-containing antacid, it may be wise to separate the administration of phosphorus salts from calcium-containing products. In some instances the administration of calcium salts or calcium carbonate is used therapeutically (e.g., uremia) to decrease serum phosphorus levels, so the administration of phosphorus supplements would dynamically counteract the intended use of calcium in these settings, assuming hypophosphatemia is not present. Appropriate calcium-phosphorus ratios in vivo are important for proper calcium homeostasis in tissues and bone; if the serum ionized calcium concentration is elevated, the concomitant use of calcium salts and phosphorus salts may increase the risk of calcium deposition in soft tissue. [31028] [57713] [57714] [57715] Ibuprofen; Famotidine: (Minor) The bioavailability of oral iron salts is influenced by gastric pH, and the concomitant administration of H2-blockers can decrease iron absorption. The non-heme ferric form of iron needs an acidic intragastric pH to be reduced to ferrous and to be absorbed. Iron salts and polysaccharide-iron complex provide non-heme iron. H2-blockers have long-lasting effects on the secretion of gastric acid and thus, increase the pH of the stomach. The increase in intragastric pH can interfere with the absorption of iron salts. [6305] Irbesartan; Hydrochlorothiazide, HCTZ: (Moderate) Monitor serum calcium concentration during concomitant calcium and thiazide diuretic use due to the risk for hypercalcemia. Thiazide diuretics may decrease urinary calcium excretion and cause intermittent and slight increases in serum calcium. [48850] [63883] Iron - Injectable Only: (Major) Parenteral iron formulas are generally only indicated for use in patients with documented iron deficiency in whom oral administration is either impossible or unsatisfactory. In general, do not administer parenteral iron concomitantly with other iron preparations (e.g., other parenteral iron products or oral iron supplements). Parenteral iron preparations (e.g., iron dextran; iron sucrose, sucroferric oxyhydroxide; sodium ferric gluconate complex; ferric carboxymaltose; ferumoxytol) may reduce the absorption of concomitantly administered oral iron preparations. Oral iron supplementation should be discontinued before parenteral administration of iron. Too much iron can be toxic, and iron is not easily eliminated from the body. [29895] [42291] Iron Dextran: (Major) Parenteral iron formulas are generally only indicated for use in patients with documented iron deficiency in whom oral administration is either impossible or unsatisfactory. In general, do not administer parenteral iron concomitantly with other iron preparations (e.g., other parenteral iron products or oral iron supplements). Parenteral iron preparations (e.g., iron dextran; iron sucrose, sucroferric oxyhydroxide; sodium ferric gluconate complex; ferric carboxymaltose; ferumoxytol) may reduce the absorption of concomitantly administered oral iron preparations. Oral iron supplementation should be discontinued before parenteral administration of iron. Too much iron can be toxic, and iron is not easily eliminated from the body. [29895] [42291] Iron Sucrose, Sucroferric Oxyhydroxide: (Major) Parenteral iron formulas are generally only indicated for use in patients with documented iron deficiency in whom oral administration is either impossible or unsatisfactory. In general, do not administer parenteral iron concomitantly with other iron preparations (e.g., other parenteral iron products or oral iron supplements). Parenteral iron preparations (e.g., iron dextran; iron sucrose, sucroferric oxyhydroxide; sodium ferric gluconate complex; ferric carboxymaltose; ferumoxytol) may reduce the absorption of concomitantly administered oral iron preparations. Oral iron supplementation should be discontinued before parenteral administration of iron. Too much iron can be toxic, and iron is not easily eliminated from the body. [29895] [42291] Isradipine: (Minor) Monitor blood pressure during concurrent use of calcium and calcium-channel blockers. Concomitant use may reduce the response to calcium-channel blockers. [53985] [69004] Lansoprazole: (Moderate) The bioavailability of oral iron salts is influenced by gastric pH, and the concomitant administration of proton pump inhibitors can decrease iron absorption. The non-heme ferric form of iron needs an acidic intragastric pH to be reduced to ferrous and to be absorbed. Iron salts and polysaccharide-iron complex provide non-heme iron. Proton pump inhibitors have long-lasting effects on the secretion of gastric acid and thus, increase the pH of the stomach. The increase in intragastric pH can interfere with the absorption of iron salts. [29564] [35599] [48854] Lansoprazole; Amoxicillin; Clarithromycin: (Moderate) The bioavailability of oral iron salts is influenced by gastric pH, and the concomitant administration of proton pump inhibitors can decrease iron absorption. The non-heme ferric form of iron needs an acidic intragastric pH to be reduced to ferrous and to be absorbed. Iron salts and polysaccharide-iron complex provide non-heme iron. Proton pump inhibitors have long-lasting effects on the secretion of gastric acid and thus, increase the pH of the stomach. The increase in intragastric pH can interfere with the absorption of iron salts. [29564] [35599] [48854] Lanthanum Carbonate: (Major) Oral compounds known to interact with antacids, like iron salts, should not be taken within 2 hours of dosing with lanthanum carbonate. If these agents are used concomitantly, space the dosing intervals appropriately. Monitor serum concentrations and clinical condition. [9126] Levamlodipine: (Minor) Monitor blood pressure during concurrent use of calcium and calcium-channel blockers. Concomitant use may reduce the response to calcium-channel blockers. [53985] [69004] Levodopa: (Moderate) Administration of iron salts, including polysaccharide-iron complex or multivitamins containing iron, should be separated from oral levodopa by at least 2 hours to avoid reduction in levodopa efficacy. Iron salts may reduce the bioavailability of levodopa and carbidopa; levodopa products. [48681] [52387] [58735] [58749] [58757] [63854] Levofloxacin: (Moderate) Administer oral products that contain calcium at least 2 hours before or 2 hours after orally administered levofloxacin. Levofloxacin absorption may be reduced as quinolone antibiotics can chelate with divalent or trivalent cations. Chelation of divalent cations with levofloxacin is less than with other quinolones. Examples of compounds that may interfere with quinolone bioavailability include antacids and multivitamins that contain calcium. [27973] [40284] [40285] [40286] [40287] [65562] (Moderate) Administer oral products that contain iron at least 2 hours before or 2 hours after orally administered levofloxacin. Levofloxacin absorption may be reduced as quinolone antibiotics can chelate with divalent or trivalent cations. Chelation of divalent cations with levofloxacin is less than with other quinolones. [27973] [40285] [40286] [40287] [65562] Levonorgestrel; Ethinyl Estradiol: (Minor) Estrogens can increase calcium absorption. Use caution in patients predisposed to hypercalcemia or nephrolithiasis. [6395] Levonorgestrel; Ethinyl Estradiol; Ferrous Bisglycinate: (Minor) Estrogens can increase calcium absorption. Use caution in patients predisposed to hypercalcemia or nephrolithiasis. [6395] Levonorgestrel; Ethinyl Estradiol; Ferrous Fumarate: (Minor) Estrogens can increase calcium absorption. Use caution in patients predisposed to hypercalcemia or nephrolithiasis. [6395] Levothyroxine: (Moderate) Oral thyroid hormones should be administered at least 4 hours before or after the ingestion of iron supplements. Oral iron salts have been reported to chelate oral thyroid hormones within the GI tract when administered simultaneously, leading to decreased oral absorption of the thyroid hormone. For example, ferrous sulfate likely forms a ferric-thyroxine complex. [25544] [43942] [53562] (Moderate) Thyroid hormones should be administered at least 4 hours before or after the ingestion of oral calcium supplements. Calcium salts have been reported to chelate oral thyroid hormones within the GI tract when administered simultaneously, leading to decreased thyroid hormone absorption. Some case reports have described clinical hypothyroidism resulting from coadministration of thyroid hormones with oral calcium supplements. [27979] [43943] [44355] [53562] Levothyroxine; Liothyronine (Porcine): (Moderate) Oral thyroid hormones should be administered at least 4 hours before or after the ingestion of iron supplements. Oral iron salts have been reported to chelate oral thyroid hormones within the GI tract when administered simultaneously, leading to decreased oral absorption of the thyroid hormone. For example, ferrous sulfate likely forms a ferric-thyroxine complex. [25544] [43942] [53562] (Moderate) Thyroid hormones should be administered at least 4 hours before or after the ingestion of oral calcium supplements. Calcium salts have been reported to chelate oral thyroid hormones within the GI tract when administered simultaneously, leading to decreased thyroid hormone absorption. Some case reports have described clinical hypothyroidism resulting from coadministration of thyroid hormones with oral calcium supplements. [27979] [43943] [44355] [53562] Levothyroxine; Liothyronine (Synthetic): (Moderate) Oral thyroid hormones should be administered at least 4 hours before or after the ingestion of iron supplements. Oral iron salts have been reported to chelate oral thyroid hormones within the GI tract when administered simultaneously, leading to decreased oral absorption of the thyroid hormone. For example, ferrous sulfate likely forms a ferric-thyroxine complex. [25544] [43942] [53562] (Moderate) Thyroid hormones should be administered at least 4 hours before or after the ingestion of oral calcium supplements. Calcium salts have been reported to chelate oral thyroid hormones within the GI tract when administered simultaneously, leading to decreased thyroid hormone absorption. Some case reports have described clinical hypothyroidism resulting from coadministration of thyroid hormones with oral calcium supplements. [27979] [43943] [44355] [53562] Liothyronine: (Moderate) Oral thyroid hormones should be administered at least 4 hours before or after the ingestion of iron supplements. Oral iron salts have been reported to chelate oral thyroid hormones within the GI tract when administered simultaneously, leading to decreased oral absorption of the thyroid hormone. For example, ferrous sulfate likely forms a ferric-thyroxine complex. [25544] [43942] [53562] (Moderate) Thyroid hormones should be administered at least 4 hours before or after the ingestion of oral calcium supplements. Calcium salts have been reported to chelate oral thyroid hormones within the GI tract when administered simultaneously, leading to decreased thyroid hormone absorption. Some case reports have described clinical hypothyroidism resulting from coadministration of thyroid hormones with oral calcium supplements. [27979] [43943] [44355] [53562] Lisinopril; Hydrochlorothiazide, HCTZ: (Moderate) Monitor serum calcium concentration during concomitant calcium and thiazide diuretic use due to the risk for hypercalcemia. Thiazide diuretics may decrease urinary calcium excretion and cause intermittent and slight increases in serum calcium. [48850] [63883] Lithium: (Moderate) Monitor serum calcium concentrations closely if concomitant use of calcium and lithium is necessary. Concomitant use may increase the risk of hypercalcemia. [53985] Losartan; Hydrochlorothiazide, HCTZ: (Moderate) Monitor serum calcium concentration during concomitant calcium and thiazide diuretic use due to the risk for hypercalcemia. Thiazide diuretics may decrease urinary calcium excretion and cause intermittent and slight increases in serum calcium. [48850] [63883] Magnesium Hydroxide: (Moderate) Doses of antacids and iron should be taken as far apart as possible to minimize the potential for interaction. Antacids may decrease the absorption of oral iron preparations. At higher pH values, iron is more readily ionized to its ferric state and is more poorly absorbed. [27981] Magnesium Salts: (Moderate) Doses of antacids and iron should be taken as far apart as possible to minimize the potential for interaction. Antacids may decrease the absorption of oral iron preparations. At higher pH values, iron is more readily ionized to its ferric state and is more poorly absorbed. [27981] Magnesium Sulfate; Potassium Sulfate; Sodium Sulfate: (Major) Administer iron at least 2 hours before or 6 hours after administration of magnesium sulfate; potassium sulfate; sodium sulfate. The absorption of iron may be reduced by chelation with magnesium sulfate. [41573] Methyldopa: (Major) Coadministration of methyldopa with iron salts or polysaccharide-iron complex is not recommended. If iron supplementation is necessary, administer a methyldopa dose at least 2 hours prior to the iron supplement. Iron salts have been reported to dramatically reduce the oral absorption of methyldopa. Several studies demonstrate decreased bioavailability of methyldopa when coadministered with ferrous sulfate or ferrous gluconate. This interaction may result in decreased antihypertensive effect of methyldopa. [29252] Metolazone: (Moderate) Monitor serum calcium concentration during concomitant calcium and thiazide diuretic use due to the risk for hypercalcemia. Thiazide diuretics may decrease urinary calcium excretion and cause intermittent and slight increases in serum calcium. [48850] [63883] Metoprolol; Hydrochlorothiazide, HCTZ: (Moderate) Monitor serum calcium concentration during concomitant calcium and thiazide diuretic use due to the risk for hypercalcemia. Thiazide diuretics may decrease urinary calcium excretion and cause intermittent and slight increases in serum calcium. [48850] [63883] Minocycline: (Moderate) Divalent or trivalent cations readily chelate with tetracycline antibiotics, forming insoluble compounds. The oral absorption of these antibiotics will be significantly reduced by other orally administered compounds that contain calcium salts, particularly if the time of administration is within 60 minutes of each other. Calcium salts and tetracyclines should not be administered within 1 to 2 hours of each other, although doxycycline chelates less with calcium than other tetracyclines. [4691] [6707] (Moderate) Separate administration of tetracyclines and iron by 2 to 3 hours. Iron may decrease the oral bioavailability of tetracyclines. [27974] [29959] [64502] [67408] Moxifloxacin: (Major) Administer oral moxifloxacin at least 4 hours before or 8 hours after oral products that contain calcium. Moxifloxacin absorption may be reduced as quinolone antibiotics can chelate with divalent or trivalent cations. Examples of compounds that may interfere with quinolone bioavailability include antacids and multivitamins that contain calcium. [27973] [28423] [40284] [40285] [40286] [40287] (Major) Administer oral moxifloxacin at least 4 hours before or 8 hours after oral products that contain iron. Moxifloxacin absorption may be reduced as quinolone antibiotics can chelate with divalent or trivalent cations. Examples of compounds that may interfere with quinolone bioavailability include multivitamins that contain iron. [27973] [28423] [40285] [40286] [40287] Mycophenolate: (Moderate) Separate administration of mycophenolate and iron by at least 4 hours. Iron may decrease the oral bioavailability of mycophenolate. Mycophenolate recovery was reduced by up to 16% under certain pH conditions in drug interaction studies. [29993] [64502] [67405] Naproxen; Esomeprazole: (Moderate) The bioavailability of oral iron salts is influenced by gastric pH, and the concomitant administration of proton pump inhibitors can decrease iron absorption. The non-heme ferric form of iron needs an acidic intragastric pH to be reduced to ferrous and to be absorbed. Iron salts and polysaccharide-iron complex provide non-heme iron. Proton pump inhibitors have long-lasting effects on the secretion of gastric acid and thus, increase the pH of the stomach. The increase in intragastric pH can interfere with the absorption of iron salts. [29564] [35599] [48854] Neuromuscular blockers: (Moderate) Concomitant use of neuromuscular blockers and calcium may result in resistance to neuromuscular blockade. Calcium antagonizes the potentiating effect of magnesium on neuromuscular blockade. Also, calcium triggers acetylcholine release, and therefore, may both reduce the sensitivity to neuromuscular blockers and decrease the duration of neuromuscular blockade. [65345] Nicardipine: (Minor) Monitor blood pressure during concurrent use of calcium and calcium-channel blockers. Concomitant use may reduce the response to calcium-channel blockers. [53985] [69004] NIFEdipine: (Minor) Monitor blood pressure during concurrent use of calcium and calcium-channel blockers. Concomitant use may reduce the response to calcium-channel blockers. [53985] [69004] Nimodipine: (Minor) Monitor blood pressure during concurrent use of calcium and calcium-channel blockers. Concomitant use may reduce the response to calcium-channel blockers. [53985] [69004] Nisoldipine: (Minor) Monitor blood pressure during concurrent use of calcium and calcium-channel blockers. Concomitant use may reduce the response to calcium-channel blockers. [53985] [69004] Nizatidine: (Minor) The bioavailability of oral iron salts is influenced by gastric pH, and the concomitant administration of H2-blockers can decrease iron absorption. The non-heme ferric form of iron needs an acidic intragastric pH to be reduced to ferrous and to be absorbed. Iron salts and polysaccharide-iron complex provide non-heme iron. H2-blockers have long-lasting effects on the secretion of gastric acid and thus, increase the pH of the stomach. The increase in intragastric pH can interfere with the absorption of iron salts. [6305] Norethindrone Acetate; Ethinyl Estradiol; Ferrous fumarate: (Minor) Estrogens can increase calcium absorption. Use caution in patients predisposed to hypercalcemia or nephrolithiasis. [6395] Norethindrone; Ethinyl Estradiol: (Minor) Estrogens can increase calcium absorption. Use caution in patients predisposed to hypercalcemia or nephrolithiasis. [6395] Norethindrone; Ethinyl Estradiol; Ferrous fumarate: (Minor) Estrogens can increase calcium absorption. Use caution in patients predisposed to hypercalcemia or nephrolithiasis. [6395] Norgestimate; Ethinyl Estradiol: (Minor) Estrogens can increase calcium absorption. Use caution in patients predisposed to hypercalcemia or nephrolithiasis. [6395] Ofloxacin: (Moderate) Administer oral products that contain calcium at least 2 hours before or 2 hours after ofloxacin. Ofloxacin absorption may be reduced as quinolone antibiotics can chelate with divalent or trivalent cations. Examples of compounds that may interfere with quinolone bioavailability include antacids and multivitamins that contain calcium. [30738] (Moderate) Administer oral products that contain iron at least 2 hours before or 2 hours after ofloxacin. Ofloxacin absorption may be reduced as quinolone antibiotics can chelate with divalent or trivalent cations. [30738] Olmesartan; Amlodipine; Hydrochlorothiazide, HCTZ: (Moderate) Monitor serum calcium concentration during concomitant calcium and thiazide diuretic use due to the risk for hypercalcemia. Thiazide diuretics may decrease urinary calcium excretion and cause intermittent and slight increases in serum calcium. [48850] [63883] (Minor) Monitor blood pressure during concurrent use of calcium and calcium-channel blockers. Concomitant use may reduce the response to calcium-channel blockers. [53985] [69004] Olmesartan; Hydrochlorothiazide, HCTZ: (Moderate) Monitor serum calcium concentration during concomitant calcium and thiazide diuretic use due to the risk for hypercalcemia. Thiazide diuretics may decrease urinary calcium excretion and cause intermittent and slight increases in serum calcium. [48850] [63883] Omadacycline: (Moderate) Divalent or trivalent cations readily chelate with tetracycline antibiotics, forming insoluble compounds. The oral absorption of these antibiotics will be significantly reduced by other orally administered compounds that contain calcium salts, particularly if the time of administration is within 60 minutes of each other. Calcium salts and tetracyclines should not be administered within 1 to 2 hours of each other, although doxycycline chelates less with calcium than other tetracyclines. [4691] [6707] (Moderate) Separate administration of tetracyclines and iron by 2 to 3 hours. Iron may decrease the oral bioavailability of tetracyclines. [27974] [29959] [64502] [67408] Omeprazole: (Moderate) The bioavailability of oral iron salts is influenced by gastric pH, and the concomitant administration of proton pump inhibitors can decrease iron absorption. The non-heme ferric form of iron needs an acidic intragastric pH to be reduced to ferrous and to be absorbed. Iron salts and polysaccharide-iron complex provide non-heme iron. Proton pump inhibitors have long-lasting effects on the secretion of gastric acid and thus, increase the pH of the stomach. The increase in intragastric pH can interfere with the absorption of iron salts. [29564] [35599] [48854] Omeprazole; Amoxicillin; Rifabutin: (Moderate) The bioavailability of oral iron salts is influenced by gastric pH, and the concomitant administration of proton pump inhibitors can decrease iron absorption. The non-heme ferric form of iron needs an acidic intragastric pH to be reduced to ferrous and to be absorbed. Iron salts and polysaccharide-iron complex provide non-heme iron. Proton pump inhibitors have long-lasting effects on the secretion of gastric acid and thus, increase the pH of the stomach. The increase in intragastric pH can interfere with the absorption of iron salts. [29564] [35599] [48854] Omeprazole; Sodium Bicarbonate: (Moderate) Doses of antacids and iron should be taken as far apart as possible to minimize the potential for interaction. Antacids may decrease the absorption of oral iron preparations. At higher pH values, iron is more readily ionized to its ferric state and is more poorly absorbed. [27981] (Moderate) The bioavailability of oral iron salts is influenced by gastric pH, and the concomitant administration of proton pump inhibitors can decrease iron absorption. The non-heme ferric form of iron needs an acidic intragastric pH to be reduced to ferrous and to be absorbed. Iron salts and polysaccharide-iron complex provide non-heme iron. Proton pump inhibitors have long-lasting effects on the secretion of gastric acid and thus, increase the pH of the stomach. The increase in intragastric pH can interfere with the absorption of iron salts. [29564] [35599] [48854] Pancuronium: (Moderate) Concomitant use of neuromuscular blockers and calcium may result in resistance to neuromuscular blockade. Calcium antagonizes the potentiating effect of magnesium on neuromuscular blockade. Also, calcium triggers acetylcholine release, and therefore, may both reduce the sensitivity to neuromuscular blockers and decrease the duration of neuromuscular blockade. [65345] Pantoprazole: (Moderate) The bioavailability of oral iron salts is influenced by gastric pH, and the concomitant administration of proton pump inhibitors can decrease iron absorption. The non-heme ferric form of iron needs an acidic intragastric pH to be reduced to ferrous and to be absorbed. Iron salts and polysaccharide-iron complex provide non-heme iron. Proton pump inhibitors have long-lasting effects on the secretion of gastric acid and thus, increase the pH of the stomach. The increase in intragastric pH can interfere with the absorption of iron salts. [29564] [35599] [48854] Parathyroid Hormone: (Moderate) Monitor serum calcium concentrations closely if concomitant use of calcium and parathyroid hormone is necessary. Concomitant use may increase the risk of hypercalcemia. [53985] Paricalcitol: (Moderate) Monitor serum calcium concentrations during concomitant use of high doses of calcium and vitamin D analogs; a dosage adjustment of the vitamin D analog may be needed. Hypercalcemia may be exacerbated by concomitant administration. [28490] [30153] [60895] Penicillamine: (Major) In general, oral mineral supplements should not be given since they may block the oral absorption of penicillamine. However, iron deficiency may develop, especially in children and menstruating or pregnant women, or as a result of the low copper diet recommended for Wilson's disease. If necessary, iron may be given in short courses, but since iron and penicillamine each inhibit oral absorption of the other, 2 hours should elapse between administration of penicillamine and iron doses. [28834] [41825] [60665] Perindopril; Amlodipine: (Minor) Monitor blood pressure during concurrent use of calcium and calcium-channel blockers. Concomitant use may reduce the response to calcium-channel blockers. [53985] [69004] Phosphorated Carbohydrate Solution: (Moderate) It has been reported that high intakes of phosphates, such as are found in dietary supplements or food additives, can interfere with absorption of trace nutrients such as iron, copper, and zinc. The magnitude of the effect may be small, and the interactions require further study to judge clinical significance. The theorized mechanism is the formation of insoluble complexes within the gut. Until more data are available, it may be helpful to separate administration times of phosphates by as much as possible from the oral administration of iron (e.g., iron salts or polysaccharide-iron complex), copper salts, or zinc salts to limit any potential interactions. [29060] [29985] [30998] [31028] (Moderate) The oral absorption of phosphorus is reduced by ingestion of pharmacologic doses of calcium carbonate or other phosphate-lowering calcium salts (e.g., calcium acetate). There is, however, no significant interference with phosphorus absorption by oral dietary calcium at intakes within the typical adult range. If the patient requires multiple calcium supplements or a calcium-containing antacid, it may be wise to separate the administration of phosphorus salts from calcium-containing products. In some instances the administration of calcium salts or calcium carbonate is used therapeutically (e.g., uremia) to decrease serum phosphorus levels, so the administration of phosphorus supplements would dynamically counteract the intended use of calcium in these settings, assuming hypophosphatemia is not present. Appropriate calcium-phosphorus ratios in vivo are important for proper calcium homeostasis in tissues and bone; if the serum ionized calcium concentration is elevated, the concomitant use of calcium salts and phosphorus salts may increase the risk of calcium deposition in soft tissue. [31028] [57713] [57714] [57715] Phosphorus: (Moderate) It has been reported that high intakes of phosphates, such as are found in dietary supplements or food additives, can interfere with absorption of trace nutrients such as iron, copper, and zinc. The magnitude of the effect may be small, and the interactions require further study to judge clinical significance. The theorized mechanism is the formation of insoluble complexes within the gut. Until more data are available, it may be helpful to separate administration times of phosphates by as much as possible from the oral administration of iron (e.g., iron salts or polysaccharide-iron complex), copper salts, or zinc salts to limit any potential interactions. [29060] [29985] [30998] [31028] (Moderate) The oral absorption of phosphorus is reduced by ingestion of pharmacologic doses of calcium carbonate or other phosphate-lowering calcium salts (e.g., calcium acetate). There is, however, no significant interference with phosphorus absorption by oral dietary calcium at intakes within the typical adult range. If the patient requires multiple calcium supplements or a calcium-containing antacid, it may be wise to separate the administration of phosphorus salts from calcium-containing products. In some instances the administration of calcium salts or calcium carbonate is used therapeutically (e.g., uremia) to decrease serum phosphorus levels, so the administration of phosphorus supplements would dynamically counteract the intended use of calcium in these settings, assuming hypophosphatemia is not present. Appropriate calcium-phosphorus ratios in vivo are important for proper calcium homeostasis in tissues and bone; if the serum ionized calcium concentration is elevated, the concomitant use of calcium salts and phosphorus salts may increase the risk of calcium deposition in soft tissue. [31028] [57713] [57714] [57715] Polyethylene Glycol; Electrolytes: (Major) Administer iron at least 2 hours before or 6 hours after administration of magnesium sulfate; potassium sulfate; sodium sulfate. The absorption of iron may be reduced by chelation with magnesium sulfate. [41573] Polyethylene Glycol; Electrolytes; Ascorbic Acid: (Major) Administer iron at least 2 hours before or 6 hours after administration of magnesium sulfate; potassium sulfate; sodium sulfate. The absorption of iron may be reduced by chelation with magnesium sulfate. [41573] Potassium Phosphate: (Moderate) It has been reported that high intakes of phosphates, such as are found in dietary supplements or food additives, can interfere with absorption of trace nutrients such as iron, copper, and zinc. The magnitude of the effect may be small, and the interactions require further study to judge clinical significance. The theorized mechanism is the formation of insoluble complexes within the gut. Until more data are available, it may be helpful to separate administration times of phosphates by as much as possible from the oral administration of iron (e.g., iron salts or polysaccharide-iron complex), copper salts, or zinc salts to limit any potential interactions. [29060] [29985] [30998] [31028] (Moderate) The oral absorption of phosphorus is reduced by ingestion of pharmacologic doses of calcium carbonate or other phosphate-lowering calcium salts (e.g., calcium acetate). There is, however, no significant interference with phosphorus absorption by oral dietary calcium at intakes within the typical adult range. If the patient requires multiple calcium supplements or a calcium-containing antacid, it may be wise to separate the administration of phosphorus salts from calcium-containing products. In some instances the administration of calcium salts or calcium carbonate is used therapeutically (e.g., uremia) to decrease serum phosphorus levels, so the administration of phosphorus supplements would dynamically counteract the intended use of calcium in these settings, assuming hypophosphatemia is not present. Appropriate calcium-phosphorus ratios in vivo are important for proper calcium homeostasis in tissues and bone; if the serum ionized calcium concentration is elevated, the concomitant use of calcium salts and phosphorus salts may increase the risk of calcium deposition in soft tissue. [31028] [57713] [57714] [57715] Potassium Phosphate; Sodium Phosphate: (Moderate) It has been reported that high intakes of phosphates, such as are found in dietary supplements or food additives, can interfere with absorption of trace nutrients such as iron, copper, and zinc. The magnitude of the effect may be small, and the interactions require further study to judge clinical significance. The theorized mechanism is the formation of insoluble complexes within the gut. Until more data are available, it may be helpful to separate administration times of phosphates by as much as possible from the oral administration of iron (e.g., iron salts or polysaccharide-iron complex), copper salts, or zinc salts to limit any potential interactions. [29060] [29985] [30998] [31028] (Moderate) The oral absorption of phosphorus is reduced by ingestion of pharmacologic doses of calcium carbonate or other phosphate-lowering calcium salts (e.g., calcium acetate). There is, however, no significant interference with phosphorus absorption by oral dietary calcium at intakes within the typical adult range. If the patient requires multiple calcium supplements or a calcium-containing antacid, it may be wise to separate the administration of phosphorus salts from calcium-containing products. In some instances the administration of calcium salts or calcium carbonate is used therapeutically (e.g., uremia) to decrease serum phosphorus levels, so the administration of phosphorus supplements would dynamically counteract the intended use of calcium in these settings, assuming hypophosphatemia is not present. Appropriate calcium-phosphorus ratios in vivo are important for proper calcium homeostasis in tissues and bone; if the serum ionized calcium concentration is elevated, the concomitant use of calcium salts and phosphorus salts may increase the risk of calcium deposition in soft tissue. [31028] [57713] [57714] [57715] Proton pump inhibitors: (Moderate) The bioavailability of oral iron salts is influenced by gastric pH, and the concomitant administration of proton pump inhibitors can decrease iron absorption. The non-heme ferric form of iron needs an acidic intragastric pH to be reduced to ferrous and to be absorbed. Iron salts and polysaccharide-iron complex provide non-heme iron. Proton pump inhibitors have long-lasting effects on the secretion of gastric acid and thus, increase the pH of the stomach. The increase in intragastric pH can interfere with the absorption of iron salts. [29564] [35599] [48854] Quinapril; Hydrochlorothiazide, HCTZ: (Moderate) Monitor serum calcium concentration during concomitant calcium and thiazide diuretic use due to the risk for hypercalcemia. Thiazide diuretics may decrease urinary calcium excretion and cause intermittent and slight increases in serum calcium. [48850] [63883] Rabeprazole: (Moderate) The bioavailability of oral iron salts is influenced by gastric pH, and the concomitant administration of proton pump inhibitors can decrease iron absorption. The non-heme ferric form of iron needs an acidic intragastric pH to be reduced to ferrous and to be absorbed. Iron salts and polysaccharide-iron complex provide non-heme iron. Proton pump inhibitors have long-lasting effects on the secretion of gastric acid and thus, increase the pH of the stomach. The increase in intragastric pH can interfere with the absorption of iron salts. [29564] [35599] [48854] Ranitidine: (Minor) The bioavailability of oral iron salts is influenced by gastric pH, and the concomitant administration of H2-blockers can decrease iron absorption. The non-heme ferric form of iron needs an acidic intragastric pH to be reduced to ferrous and to be absorbed. Iron salts and polysaccharide-iron complex provide non-heme iron. H2-blockers have long-lasting effects on the secretion of gastric acid and thus, increase the pH of the stomach. The increase in intragastric pH can interfere with the absorption of iron salts. [6305] Relugolix; Estradiol; Norethindrone acetate: (Minor) Estrogens can increase calcium absorption. Use caution in patients predisposed to hypercalcemia or nephrolithiasis. [6395] Risedronate: (Moderate) Separate administration of oral risedronate and calcium-containing supplements by at least 2 hours. Calcium will interfere with the absorption of oral risedronate. [29352] [42080] (Moderate) Separate administration of oral risedronate and iron supplements by at least 2 hours. Iron will interfere with the absorption of oral risedronate. [29352] [42080] Rocuronium: (Moderate) Concomitant use of neuromuscular blockers and calcium may result in resistance to neuromuscular blockade. Calcium antagonizes the potentiating effect of magnesium on neuromuscular blockade. Also, calcium triggers acetylcholine release, and therefore, may both reduce the sensitivity to neuromuscular blockers and decrease the duration of neuromuscular blockade. [65345] Sarecycline: (Moderate) Divalent or trivalent cations readily chelate with tetracycline antibiotics, forming insoluble compounds. The oral absorption of these antibiotics will be significantly reduced by other orally administered compounds that contain calcium salts, particularly if the time of administration is within 60 minutes of each other. Calcium salts and tetracyclines should not be administered within 1 to 2 hours of each other, although doxycycline chelates less with calcium than other tetracyclines. [4691] [6707] (Moderate) Separate administration of tetracyclines and iron by 2 to 3 hours. Iron may decrease the oral bioavailability of tetracyclines. [27974] [29959] [64502] [67408] Segesterone Acetate; Ethinyl Estradiol: (Minor) Estrogens can increase calcium absorption. Use caution in patients predisposed to hypercalcemia or nephrolithiasis. [6395] Sodium Bicarbonate: (Moderate) Doses of antacids and iron should be taken as far apart as possible to minimize the potential for interaction. Antacids may decrease the absorption of oral iron preparations. At higher pH values, iron is more readily ionized to its ferric state and is more poorly absorbed. [27981] Sodium Fluoride: (Moderate) Absorption of sodium fluoride may be reduced by concomitant use of antacids that contain magnesium, aluminum, or calcium. An interval of at least 2 hours is advisable between administration of sodium fluoride and antacids. [6085] Sodium Phosphate Monobasic Monohydrate; Sodium Phosphate Dibasic Anhydrous: (Moderate) The concomitant use of oral sodium phosphate monobasic monohydrate; sodium phosphate dibasic anhydrous preparations in conjunction with antacids containing calcium (e.g., calcium carbonate, calcium salts) may bind the phosphate in the stomach and reduce its absorption. If the patient requires multiple mineral supplements or concurrent use of antacids, it is prudent to separate the administration of sodium phosphate salts from calcium containing products by at least one hour. [7800] Sodium picosulfate; Magnesium oxide; Anhydrous citric acid: (Moderate) Iron salts may chelate with the magnesium in sodium picosulfate; magnesium oxide; anhydrous citric acid solution. Therefore, products containing iron should be taken at least 2 hours before and not less than 6 hours after the administration of sodium picosulfate; magnesium oxide; anhydrous citric acid solution. [51258] Spironolactone; Hydrochlorothiazide, HCTZ: (Moderate) Monitor serum calcium concentration during concomitant calcium and thiazide diuretic use due to the risk for hypercalcemia. Thiazide diuretics may decrease urinary calcium excretion and cause intermittent and slight increases in serum calcium. [48850] [63883] Succinylcholine: (Moderate) Concomitant use of neuromuscular blockers and calcium may result in resistance to neuromuscular blockade. Calcium antagonizes the potentiating effect of magnesium on neuromuscular blockade. Also, calcium triggers acetylcholine release, and therefore, may both reduce the sensitivity to neuromuscular blockers and decrease the duration of neuromuscular blockade. [65345] Sulfacetamide; Sulfur: (Major) Because edetate disodium chelates and lowers serum calcium, oral or parenteral calcium salts should not be administered concomitantly. [7090] Telmisartan; Amlodipine: (Minor) Monitor blood pressure during concurrent use of calcium and calcium-channel blockers. Concomitant use may reduce the response to calcium-channel blockers. [53985] [69004] Telmisartan; Hydrochlorothiazide, HCTZ: (Moderate) Monitor serum calcium concentration during concomitant calcium and thiazide diuretic use due to the risk for hypercalcemia. Thiazide diuretics may decrease urinary calcium excretion and cause intermittent and slight increases in serum calcium. [48850] [63883] Teriparatide: (Moderate) Monitor serum calcium concentrations closely if concomitant use of calcium and teriparatide is necessary. Concomitant use may increase the risk of hypercalcemia. [53985] Tetracycline: (Moderate) Divalent or trivalent cations readily chelate with tetracycline antibiotics, forming insoluble compounds. The oral absorption of these antibiotics will be significantly reduced by other orally administered compounds that contain calcium salts, particularly if the time of administration is within 60 minutes of each other. Calcium salts and tetracyclines should not be administered within 1 to 2 hours of each other, although doxycycline chelates less with calcium than other tetracyclines. [4691] [6707] (Moderate) Separate administration of tetracyclines and iron by 2 to 3 hours. Iron may decrease the oral bioavailability of tetracyclines. [27974] [29959] [64502] [67408] Tetracyclines: (Moderate) Divalent or trivalent cations readily chelate with tetracycline antibiotics, forming insoluble compounds. The oral absorption of these antibiotics will be significantly reduced by other orally administered compounds that contain calcium salts, particularly if the time of administration is within 60 minutes of each other. Calcium salts and tetracyclines should not be administered within 1 to 2 hours of each other, although doxycycline chelates less with calcium than other tetracyclines. [4691] [6707] (Moderate) Separate administration of tetracyclines and iron by 2 to 3 hours. Iron may decrease the oral bioavailability of tetracyclines. [27974] [29959] [64502] [67408] Thiazide diuretics: (Moderate) Monitor serum calcium concentration during concomitant calcium and thiazide diuretic use due to the risk for hypercalcemia. Thiazide diuretics may decrease urinary calcium excretion and cause intermittent and slight increases in serum calcium. [48850] [63883] Thyroid hormones: (Moderate) Oral thyroid hormones should be administered at least 4 hours before or after the ingestion of iron supplements. Oral iron salts have been reported to chelate oral thyroid hormones within the GI tract when administered simultaneously, leading to decreased oral absorption of the thyroid hormone. For example, ferrous sulfate likely forms a ferric-thyroxine complex. [25544] [43942] [53562] (Moderate) Thyroid hormones should be administered at least 4 hours before or after the ingestion of oral calcium supplements. Calcium salts have been reported to chelate oral thyroid hormones within the GI tract when administered simultaneously, leading to decreased thyroid hormone absorption. Some case reports have described clinical hypothyroidism resulting from coadministration of thyroid hormones with oral calcium supplements. [27979] [43943] [44355] [53562] Trandolapril; Verapamil: (Minor) Monitor blood pressure during concurrent use of calcium and calcium-channel blockers. Concomitant use may reduce the response to calcium-channel blockers. [53985] [69004] Triamterene; Hydrochlorothiazide, HCTZ: (Moderate) Monitor serum calcium concentration during concomitant calcium and thiazide diuretic use due to the risk for hypercalcemia. Thiazide diuretics may decrease urinary calcium excretion and cause intermittent and slight increases in serum calcium. [48850] [63883] Trientine: (Major) In general, oral mineral supplements should not be given since they may block the oral absorption of trientine. However, iron deficiency may develop, especially in children and menstruating or pregnant women, or as a result of the low copper diet recommended for Wilson's disease. If necessary, iron may be given in short courses, but since iron and trientine each inhibit oral absorption of the other, 2 hours should elapse between administration of trientine and iron doses. [10005] [41825] Valsartan; Hydrochlorothiazide, HCTZ: (Moderate) Monitor serum calcium concentration during concomitant calcium and thiazide diuretic use due to the risk for hypercalcemia. Thiazide diuretics may decrease urinary calcium excretion and cause intermittent and slight increases in serum calcium. [48850] [63883] Vecuronium: (Moderate) Concomitant use of neuromuscular blockers and calcium may result in resistance to neuromuscular blockade. Calcium antagonizes the potentiating effect of magnesium on neuromuscular blockade. Also, calcium triggers acetylcholine release, and therefore, may both reduce the sensitivity to neuromuscular blockers and decrease the duration of neuromuscular blockade. [65345] Verapamil: (Minor) Monitor blood pressure during concurrent use of calcium and calcium-channel blockers. Concomitant use may reduce the response to calcium-channel blockers. [53985] [69004] Vitamin A: (Minor) Doses in excess of 1,500 to 2,000 mcg per day of Vitamin A may lead to bone loss and will counteract the effects of supplementation with calcium salts. [8242] [8257] Vitamin D analogs: (Moderate) Monitor serum calcium concentrations during concomitant use of high doses of calcium and vitamin D analogs; a dosage adjustment of the vitamin D analog may be needed. Hypercalcemia may be exacerbated by concomitant administration. [28490] [30153] [60895] Vonoprazan: (Moderate) Monitor for decreased efficacy of oral iron salts if coadministered with vonoprazan. Vonoprazan reduces intragastric acidity, which may decrease the absorption of iron reducing its efficacy. [67585] Vonoprazan; Amoxicillin: (Moderate) Monitor for decreased efficacy of oral iron salts if coadministered with vonoprazan. Vonoprazan reduces intragastric acidity, which may decrease the absorption of iron reducing its efficacy. [67585] Vonoprazan; Amoxicillin; Clarithromycin: (Moderate) Monitor for decreased efficacy of oral iron salts if coadministered with vonoprazan. Vonoprazan reduces intragastric acidity, which may decrease the absorption of iron reducing its efficacy. [67585] Zinc Salts: (Moderate) Orally administered zinc salts compete with iron supplements for absorption from the intestine. To minimize the interaction, separate oral iron and zinc doses by at least 2 hours. The oral receipt of 100 mg of iron as ferrous gluconate with 12 mg zinc in 11 patients with normal iron status and comparable total exchangeable zinc pools yielded a mean zinc absorption of 26.4% +/- 14.4% of the administered dose as compared with 44.5% +/- 22.5% of the dose given without concomitant iron. Concomitant use of iron 400 mg as ferrous gluconate yielded a mean zinc absorption of 22.9% +/- 6.4% of the zinc dose. [29182] Zinc: (Moderate) Orally administered zinc salts compete with iron supplements for absorption from the intestine. To minimize the interaction, separate oral iron and zinc doses by at least 2 hours. The oral receipt of 100 mg of iron as ferrous gluconate with 12 mg zinc in 11 patients with normal iron status and comparable total exchangeable zinc pools yielded a mean zinc absorption of 26.4% +/- 14.4% of the administered dose as compared with 44.5% +/- 22.5% of the dose given without concomitant iron. Concomitant use of iron 400 mg as ferrous gluconate yielded a mean zinc absorption of 22.9% +/- 6.4% of the zinc dose. [29182]
        Revision Date: 04/11/2024, 01:57:00 AM

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        Monitoring Parameters

        • ferritin
        • hemoglobin/hematocrit
        • serum iron
        • transferrin

        US Drug Names

        • BeneHealth Ferrous Sulfate
        • Bifera
        • Duofer
        • ED-In-Sol
        • Feosol
        • Feosol Complete
        • Feosol Natural Release
        • Feratab
        • Ferate
        • Fer-Gen-Sol
        • Fergon
        • Fer-In-Sol
        • Fer-iron
        • Ferretts
        • Ferretts IPS
        • Ferrimin
        • Ferrocite
        • Ferro-Sequels
        • Hemocyte
        • ICAR
        • ICAR Pediatric
        • Iron
        • MyKidz Iron 10
        • Nephro-Fer
        • Pedia Iron
        • Proferrin ES
        • Slow Fe
        • Slow Iron
        • Tandem
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