Issues for surgery
For prevention or treatment of hypocalcaemia – risk of hypocalcaemia if omitted.
For phosphate binder – risk of hyperphosphataemia if omitted.
For osteoporosis – risk of remission if omitted for prolonged period.
Risk of hypercalcaemia if continued – see Further information.
Advice in the perioperative period
Elective surgery
Continue, including the following combination products:
- Colecalciferol with calcium carbonate – also see colecalciferol
- Calcium carbonate with calcium lactate gluconate (Calvive®)
Except:
- Risedronate with calcium carbonate and colecalciferol (follow advice in risedronate and also see colecalciferol
- Calcium carbonate used for hyperphosphataemia/phosphate binder (see below)
Consider checking calcium levels pre-operatively.
Patients taking for hyperphosphataemia (phosphate binder)
Omit dose(s) while fasting. Phosphate binders should be administered with food and not on an empty stomach, hence should be held during periods of fasting. Check phosphate levels pre-operatively.
Emergency surgery
Continue, including the following combination products:
- Colecalciferol with calcium carbonate – see also colecalciferol
- Calcium carbonate with calcium lactate gluconate (Calvive®)
Except:
- Risedronate with calcium carbonate and colecalciferol (follow advice in risedronate and also see colecalciferol
- Calcium carbonate used for hyperphosphataemia/phosphate binder (see below)
Patients taking for hyperphosphataemia (phosphate binder)
Omit dose(s) while fasting. Phosphate binders should be administered with food and not on an empty stomach, hence should be held during periods of fasting. Check phosphate levels pre-operatively.
Patients admitted with urinary calculi
Review oral calcium supplements in patients presenting with urinary calculi, as calcium supplementation may increase the risk.
Post-operative advice
Restart at usual dose once enteral intake resumed.
Monitor renal function post-operatively – a reduction in calcium dose may be required in post-operative renal impairment (see Further information).
Patients taking for hyperphosphataemia (phosphate binder)
Monitor phosphate levels post-operatively – seek advice from renal specialist if phosphate levels are not within normal limits.
Patients undergoing thyroidectomy
If patient requires both post-operative levothyroxine and calcium supplementation following thyroidectomy, they should be counselled on the need to separate administration of calcium supplementation from levothyroxine (see Interactions with other common medicines used in the perioperative period).
Patients undergoing bariatric surgery
Please refer to the British Obesity and Metabolic Surgery Society Guidelines on perioperative and post-operative biochemical monitoring and micronutrient replacement for patients undergoing bariatric surgery for post-operative management of calcium.
Interactions with common anaesthetic agents
None.
Interactions with other common medicines used in the perioperative period
Oral calcium salts may interfere with the absorption of concomitantly administered medicines. If administering medication where a reduction in bioavailability could have a clinically significant effect on safety or efficacy (e.g., antimicrobials) then administration of the medication should be separated from the calcium salt, to allow for appropriate absorption.
Common medicines used in the perioperative period where a significant reduction in bioavailability has been shown or where there is a theoretical interaction include:
- Oral quinolone antimicrobials (e.g., ciprofloxacin)
- Oral tetracycline antimicrobials (e.g., doxycycline)
- Oral iron.
Please refer to individual product literature for information on recommended time intervals.
Further information
Caution should be exercised due to risk of hypercalcaemia and milk-alkali syndrome (hypercalcaemia, alkalosis, and renal impairment) in patients on high dose therapy. The risk is higher in patients on concomitant treatment with vitamin D and/or medications or nutrients (such as milk) containing calcium. These patients should have their adjusted calcium levels and renal function monitored.
References
Summary of Product Characteristics – Calcichew® (calcium carbonate) 500mg Chewable Tablets. Neon Healthcare Ltd. Accessed via https://www.medicines.org.uk 14/03/2023 [date of revision of the text November 2021]
Summary of Product Characteristics – Calvive® (calcium carbonate, calcium lactate gluconate) 1000mg Effervescent Tablets (formerly Sandocal Tablets). Haleon UK Trading Limited. Accessed via www.medicines.org.uk 24/03/2023 [date of revision of the text January 2020]
Joint Formulary Committee. British National Formulary (online) London: BMJ Group and Pharmaceutical Press. http://www.medicinescomplete.com [Accessed on 24th March 2023]
O-Kane M, Paretti HM, Pinkeny J et al. British Obesity and Metabolic Surgery Society Guidelines on perioperative and postoperative biochemical monitoring and micronutrient replacement for bariatric patients undergoing bariatric surgery – 2020 update. Obesity Reviews 2020; 21(11); e13087.DOI:10.1111/obr.13087
Baxter K, Preston CL (eds), Stockley’s Drug Interactions (online) London: Pharmaceutical Press. http://www.medicinescomplete.com [Accessed on 24th March 2023]
Calcium. In: Brayfield A (Ed), Martindale: The Complete Drug Reference. London: The Royal Pharmaceutical Society of Great Britain. http://www.medicinescomplete.com [Accessed on 24th March 2023]