Calcium supplement

Calcium supplements are salts of calcium used in a number of conditions.[1] Supplementation is generally only required when there is not enough calcium in the diet.[2][3] By mouth they are used to treat and prevent low blood calcium, osteoporosis, and rickets.[1] By injection into a vein they are used for low blood calcium that is resulting in muscle spasms and for high blood potassium or magnesium toxicity.[2][4]

Calcium supplement
500 milligram calcium supplements made from calcium carbonate
Clinical data
Trade namesAlka-Mints, Calcet, Tums, others
AHFS/Drugs.comMonograph
License data
Pregnancy
category
  • and C
Routes of
administration		by mouth, intravenous
ATC code
Identifiers
CAS Number
ChemSpider
  • none
UNII

Common side effects include constipation and nausea.[1] When taken by mouth high blood calcium is uncommon.[1] Calcium supplements, unlike calcium from dietary sources, appear to increase the risk of kidney stones.[1] Adults generally require about a gram of calcium a day.[1] Calcium is particularly important for bones, muscles, and nerves.[1]

The medical use of calcium supplements began in the 19th century.[5] It is on the World Health Organization's List of Essential Medicines.[6] It is available as a generic medication.[3] In 2020, it was the 204th most commonly prescribed medication in the United States, with more than 2 million prescriptions.[7][8] Versions are also sold together with vitamin D.[3] In 2020, the combination, calcium/vitamin D was the 215th most commonly prescribed medication in the United States, with more than 2 million prescriptions.[7][9]

Health effects

Bone health

In healthy people, calcium supplementation is not necessary for maintaining bone mineral density, and carries risks that outweigh any benefits.[10] Calcium intake is not significantly associated with hip fracture risk in either men or women.[11] The U.S. Preventive Service Task Force recommends against a daily supplement of calcium or vitamin D.[12] Although a slight increase in bone mineral density occurred in healthy children from calcium supplementation, using additional dietary calcium is not justified, according to a 2006 review.[13]

Cardiovascular impact

There is good evidence that 1,000 mg to 1,500 mg of daily calcium supplementation can effect a modest reduction in blood pressure in adults who do not have a blood pressure condition, suggesting that achieving adequate calcium levels may have role in preventing high blood pressure.[14]

Cancer

The US National Cancer Institute does not recommend the use of calcium supplements for lowering the risk of cancer.[15] There is weak evidence calcium supplementation might have a preventative effect against developing colorectal adenomatous polyps, but the evidence is not sufficient to recommend such supplementation.[16]

Side effects

Excessive consumption of calcium carbonate antacids/dietary supplements (such as Tums) over a period of weeks or months can cause milk-alkali syndrome, with symptoms ranging from hypercalcemia to potentially fatal kidney failure. What constitutes "excessive" consumption is not well known and, it is presumed, varies a great deal from person to person. Persons consuming more than 10 grams/day of CaCO3 (=4 g Ca) are at risk of developing milk-alkali syndrome,[17] but the condition has been reported in at least one person consuming only 2.5 grams/day of CaCO3 (=1 g Ca), an amount usually considered moderate and safe.[18]

A 2023 systematic review found that calcium supplementation is not associated with myocardial infarction, stroke, heart failure admission, and cardiovascular/all-cause mortality.[19]

Calcium supplements may contribute to the development of kidney stones.[1]

Acute calcium poisoning is rare, and difficult to achieve without administering calcium intravenously. For example, the oral median lethal dose (LD50) for rats for calcium carbonate and calcium chloride are 6.45[20] and 1.4 g/kg,[21] respectively.

Interactions

Calcium supplements by mouth diminish the absorption of thyroxine when taken within four to six hours of each other.[22] Thus, people taking both calcium and thyroxine run the risk of inadequate thyroid hormone replacement and thence hypothyroidism if they take them simultaneously or near-simultaneously.[23]

Types

The intravenous formulations of calcium include calcium chloride and calcium gluconate.[1] The forms that are taken by mouth include calcium acetate, calcium carbonate, calcium citrate, calcium gluconate, calcium lactate, and calcium phosphate.[1]

  • The absorption of calcium from most food and commonly used dietary supplements is very similar.[24] This is contrary to what many calcium supplement manufacturers claim in their promotional materials.
  • Different kinds of juices boosted with calcium are widely available.
  • Calcium carbonate is the most common and least expensive calcium supplement. It should be taken with food, and depends on low pH levels (acidic) for proper absorption in the intestine.[25] Some studies suggests that the absorption of calcium from calcium carbonate is similar to the absorption of calcium from milk.[26][27]
  • Antacids frequently contain calcium carbonate, and are a commonly used, inexpensive calcium supplement.
  • Coral calcium is a salt of calcium derived from fossilized coral reefs. Coral calcium is composed of calcium carbonate and trace minerals. Claims for health benefits unique to coral calcium have been discredited.
  • Calcium citrate can be taken without food and is the supplement of choice for individuals with achlorhydria or who are taking histamine-2 blockers or proton-pump inhibitors.[28] Calcium citrate is about 21% elemental calcium. One thousand mg will provide 210 mg of calcium. It is more expensive than calcium carbonate and more of it must be taken to get the same amount of calcium.
  • Calcium phosphate costs more than calcium carbonate, but less than calcium citrate. microcrystalline hydroxyapatite (MH) is one of several forms of calcium phosphate used as a dietary supplement. Hydroxyapatite is about 40% calcium.
  • Calcium lactate has similar absorption as calcium carbonate,[29] but is more expensive. Calcium lactate and calcium gluconate are less concentrated forms of calcium and are not practical oral supplements.[28]

Vitamin D is added to some calcium supplements. Proper vitamin D status is important because vitamin D is converted to a hormone in the body, which then induces the synthesis of intestinal proteins responsible for calcium absorption.[30]

Labeling

For U.S. dietary supplement and food labeling purposes, the amount in a serving is expressed in milligrams and as a percent of Daily Value (%DV). The weight is for the calcium part of the compound – for example, calcium citrate – in the supplement. For calcium labeling purposes 100% of the Daily Value was 1000 mg, but in May 2016 it was revised to 1000–1300 mg.[31] A table of the pre-change adult Daily Values and references for the revision are provided at Reference Daily Intake. Food and supplement companies had until July 2018 to comply with the labeling change.[31]

References
  1. "Calcium Salts". The American Society of Health-System Pharmacists. Archived from the original on 18 January 2017. Retrieved 8 January 2017.
  2. World Health Organization (2009). Stuart MC, Kouimtzi M, Hill SR (eds.). WHO Model Formulary 2008. World Health Organization. p. 497. hdl:10665/44053. ISBN 9789241547659.
  3. British national formulary : BNF 69 (69 ed.). British Medical Association. 2015. pp. 694, 703. ISBN 9780857111562.
  4. Hamilton R (2015). Tarascon Pocket Pharmacopoeia 2015 Deluxe Lab-Coat Edition. Jones & Bartlett Learning. pp. 215–216. ISBN 9781284057560.
  5. Tegethoff FW (2012). Calcium Carbonate: From the Cretaceous Period into the 21st Century. Birkhäuser. p. 308. ISBN 9783034882453. Archived from the original on 16 January 2017.
  6. World Health Organization (2019). World Health Organization model list of essential medicines: 21st list 2019. Geneva: World Health Organization. hdl:10665/325771. WHO/MVP/EMP/IAU/2019.06. License: CC BY-NC-SA 3.0 IGO.
  7. "The Top 300 of 2020". ClinCalc. Retrieved 7 October 2022.
  8. "Calcium – Drug Usage Statistics". ClinCalc. Retrieved 7 October 2022.
  9. "Calcium; Vitamin D – Drug Usage Statistics". ClinCalc. Retrieved 7 October 2022.
  10. Reid IR, Bristow SM, Bolland MJ (October 2015). "Calcium supplements: benefits and risks". Journal of Internal Medicine (Review). 278 (4): 354–368. doi:10.1111/joim.12394. PMID 26174589. S2CID 4679930.
  11. Bischoff-Ferrari HA, Dawson-Hughes B, Baron JA, Burckhardt P, Li R, Spiegelman D, et al. (December 2007). "Calcium intake and hip fracture risk in men and women: a meta-analysis of prospective cohort studies and randomized controlled trials". The American Journal of Clinical Nutrition. 86 (6): 1780–1790. doi:10.1093/ajcn/86.5.1780. PMID 18065599.
  12. Moyer VA (May 2013). "Vitamin D and calcium supplementation to prevent fractures in adults: U.S. Preventive Services Task Force recommendation statement". Annals of Internal Medicine. 158 (9): 691–696. doi:10.7326/0003-4819-158-9-201305070-00603. PMID 23440163. S2CID 23008867.
  13. Winzenberg TM, Shaw K, Fryer J, Jones G (April 2006). "Calcium supplementation for improving bone mineral density in children". The Cochrane Database of Systematic Reviews. 2006 (2): CD005119. doi:10.1002/14651858.CD005119.pub2. PMC 8865374. PMID 16625624.
  14. Cormick G, Ciapponi A, Cafferata ML, Cormick MS, Belizán JM (January 2022). "Calcium supplementation for prevention of primary hypertension". The Cochrane Database of Systematic Reviews (Systematic review). 1 (1): CD010037. doi:10.1002/14651858.CD010037.pub4. PMC 8748265. PMID 35014026.
  15. "Calcium and Cancer Prevention: Strengths and Limits of the Evidence". National Cancer Institute. 4 May 2009. Archived from the original on 29 November 2014. Retrieved 2 November 2014.
  16. Weingarten MA, Zalmanovici A, Yaphe J (January 2008). "Dietary calcium supplementation for preventing colorectal cancer and adenomatous polyps". The Cochrane Database of Systematic Reviews (Review). 2008 (1): CD003548. doi:10.1002/14651858.CD003548.pub4. PMC 8719254. PMID 18254022.
  17. Beall DP, Henslee HB, Webb HR, Scofield RH (May 2006). "Milk-alkali syndrome: a historical review and description of the modern version of the syndrome". The American Journal of the Medical Sciences. 331 (5): 233–242. doi:10.1097/00000441-200605000-00001. PMID 16702792. S2CID 45802184.
  18. Picolos MK, Orlander PR (2005). "Calcium carbonate toxicity: the updated milk-alkali syndrome; report of 3 cases and review of the literature". Endocrine Practice. 11 (4): 272–280. doi:10.4158/EP.11.4.272. PMID 16006300.
  19. Sim MG, Teo YN, Teo YH, Syn NL, Li TY, Yeo LL, et al. (September 2023). "Association Between Calcium Supplementation and the Risk of Cardiovascular Disease and Stroke: A Systematic Review and Meta-Analysis". Heart, Lung & Circulation: S1443–9506(23)04281–6. doi:10.1016/j.hlc.2023.07.008. PMID 37743221. S2CID 262224167.
  20. Lewis RJ (1996). Sax's Dangerous Properties of Industrial Materials (9th ed.). New York, NY: Van Nostrand Reinhold. p. 635. ISBN 978-0-471-37858-7.
  21. ITII. Toxic and Hazardous Industrial Chemicals Safety Manual. Tokyo, Japan: The International Technical Information Institute. 1988. p. 101.
  22. Singh N, Singh PN, Hershman JM (June 2000). "Effect of calcium carbonate on the absorption of levothyroxine". JAMA. 283 (21): 2822–2825. doi:10.1001/jama.283.21.2822. PMID 10838651.
  23. Harding A. "Calcium May Help With Weight Loss". Archived from the original on 3 July 2007. Retrieved 10 July 2007.
  24. Weaver CM (2006). "29 Calcium". In Bowman BA, Russell RM (eds.). Present Knowledge in Nutrition. Vol. I (9th ed.). ILSI Press. p. 377. ISBN 978-1-57881-198-4.
  25. Remington J (2005). Remington: The Science and Practice of Pharmacy. Lippincott Williams & Wilkins. p. 1338. ISBN 978-0-7817-4673-1.
  26. Zhao Y, Martin BR, Weaver CM (October 2005). "Calcium bioavailability of calcium carbonate fortified soymilk is equivalent to cow's milk in young women" (PDF). The Journal of Nutrition. 135 (10): 2379–2382. doi:10.1093/jn/135.10.2379. PMID 16177199. Archived (PDF) from the original on 18 September 2017.
  27. Martini L, Wood RJ (December 2002). "Relative bioavailability of calcium-rich dietary sources in the elderly". The American Journal of Clinical Nutrition. 76 (6): 1345–1350. doi:10.1093/ajcn/76.6.1345. PMID 12450902.
  28. Straub DA (June 2007). "Calcium supplementation in clinical practice: a review of forms, doses, and indications". Nutrition in Clinical Practice. 22 (3): 286–296. doi:10.1177/0115426507022003286. PMID 17507729.
  29. Martin BR, Weaver CM, Heaney RP, Packard PT, Smith DL (June 2002). "Calcium absorption from three salts and CaSO(4)-fortified bread in premenopausal women". Journal of Agricultural and Food Chemistry. 50 (13): 3874–3876. doi:10.1021/jf020065g. PMID 12059174.
  30. Combs G (2008). The Vitamins. Academic Press. p. 161. ISBN 978-0-12-183490-6.
  31. "Regulations.gov". www.regulations.gov. Retrieved 18 January 2023.
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