Magnesium Sulfate - Drug Information

19/5/2014 Magnesium sulfate: Drug information
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Official reprint from UpToDate
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Magnesium sulfate: Drug information
Copyright 1978-2014 Lexicomp, Inc. All rights reserved.
(For additional information see "Magnesium sulfate: Patient drug information" and see "Magnesium sulfate:
Pediatric drug information")
For abbreviations and symbols that may be used in Lexicomp (show table)
Brand Names: U.S. Epsom Salt [OTC]
Pharmacologic Category Anticonvulsant, Miscellaneous; Electrolyte Supplement, Parenteral; Magnesium
Salt
Dosing: Adult Dose represented as magnesium sulfate unless stated otherwise. Note: Serum magnesium is
poor reflection of repletional status as the majority of magnesium is intracellular; serum concentrations may be
transiently normal for a few hours after a dose is given, therefore, aim for consistently high normal serum
concentrations in patients with normal renal function for most efficient repletion.
Note: 1 g of magnesium sulfate = 98.6 mg elemental magnesium = 8.12 mEq elemental magnesium = magnesium
4.06 mmol
Hypomagnesemia: Note: Treatment depends on severity and clinical status. In asymptomatic patients (when oral
route is available), oral replacement therapy is a better replacement method than I.V. administration.
Mild deficiency: I.M.: Manufacturer's labeling: 1 g every 6 hours for 4 doses, or as indicated by serum
magnesium concentrations
Mild-to-moderate (serum concentration 1-1.5 mg/dL): I.V.: 1-4 g (up to 0.125 g/kg), administer at 1 g/hour if
asymptomatic; do not exceed 12 g over 12 hours (Kraft, 2005). Note: Additional supplementation may be
required after the initial dose with replenishment occurring over several days.
Severe deficiency:
I.M.: Manufacturers labeling: Up to 250 mg/kg within a 4-hour period
I.V.:
Severe (<1 mg/dL): 4-8 g (up to 0.1875 g/kg), administer at 1 g/hour if asymptomatic; in
symptomatic patients, may administer 4 g over 4-5 minutes (Kraft, 2005)
With polymorphic VT (including torsade de pointes): I.V. push: 1-2 g (ACLS, 2010)
Obesity: Weight >130% of ideal body weight (IBW) or body mass index (BMI) 30 kg/m : When determining
maximum per kg dose for replacement, some clinicians suggest using adjusted body weight (AdjBW)
(Kraft, 2005).
AdjBW (men) = ([wt (kg) -IBW (kg)] x 0.3) + IBW
AdjBW (women) = ([wt (kg) -IBW (kg)] x 0.25) + IBW
Eclampsia/pre-eclampsia (severe):
2
Manufacturer's labeling: I.V.: An initial total dose of 10-14 g administered as follows: 4 g infusion with
simultaneous I.M. injections of 4-5 g in each buttock. After the initial I.V./I.M. doses, may administer a 1-2
g/hour continuous infusion or may follow with I.M. doses of 4-5 g into alternate buttocks every 4 hours as
necessary. Maximum: 40 g/24 hours. I.V. use for pre-eclampsia/eclampsia is contraindicated during the 2
hours prior to delivery.
Alternate dosing (unlabeled): I.V.: 4-6 g loading dose followed by 1-2 g/hour continuous infusion for at least 24
hours (ACOG, 2013)
Laxative: Oral: 2-6 teaspoons of granules dissolved in water once daily
Parenteral nutrition supplementation: I.V.: 8-24 mEq elemental magnesium daily
Soaking aid: Topical: Dissolve 2 cupfuls of granules per gallon of warm water
Asthma (unlabeled use): I.V. (NAEPP, 2007): 2 g
Torsade de pointes or VF/pulseless VT associated with torsade de pointes (unlabeled use): I.V., I.O.: 1-2 g
over 15 minutes (ACLS, 2010)
RDA (IOM, 1997):
Adults 19-30 years:
Females: 310 mg elemental magnesium daily
Pregnant females: 350 mg elemental magnesium daily
Breast-feeding females: 310 mg elemental magnesium daily
Males: 400 mg elemental magnesium daily
Adults 31 years:
Dosing: Pediatric
(For additional information see "Magnesium sulfate: Pediatric drug information")
Dose represented as magnesium sulfate unless stated otherwise. Note: Serum magnesium is poor reflection of
repletional status as the majority of magnesium is intracellular; serum concentrations may be transiently normal for
a few hours after a dose is given, therefore, aim for consistently high normal serum concentrations in patients with
normal renal function for most efficient repletion.
Note: 1 g of magnesium sulfate = 98.6 mg elemental magnesium = 8.12 mEq elemental magnesium = magnesium
4.06 mmol
Hypomagnesemia: Note: Treatment depends on severity and clinical status: I.V., I.O.: 25-50 mg/kg/dose over 10-
20 minutes (over several minutes for torsade de pointes); maximum single dose: 2000 mg (PALS, 2010)
Asthma (unlabeled use): I.V.: 25-75 mg/kg (maximum: 2 g) (NAEPP, 2007)
Parenteral nutrition supplementation (Mirtallo, 2004): I.V.:
<50 kg: 0.3-0.5 mEq elemental magnesium/kg/day
>50 kg: 10-30 mEq elemental magnesium daily
RDA (IOM, 1997): Children
1-3 years: 80 mg elemental magnesium daily
14-18 years:
Laxative: Oral:
Children 6-12 years: 1-2 teaspoons of granules dissolved in water once daily
Children >12 years and Adolescents: Refer to adult dosing.
Dosing: Geriatric Refer to adult dosing.
Dosing: Renal Impairment
Hypomagnesemia: Renal dysfunction: Reduce dose by 50% (Kraft, 2005). Use with caution; monitor for
hypermagnesemia; Close monitoring is required.
Pre-eclampsia/eclampsia: Severe renal impairment: Per the manufacturer, do not exceed 20 grams during a 48
hour period.
Dosing: Hepatic Impairment No dosage adjustment necessary.
Dosing: Obesity Refer to indication-specific dosing for obesity-related information (may not be available for
all indications).
Dosage Forms: U.S. Excipient information presented when available (limited, particularly for generics);
consult specific product labeling.
Capsule, Oral:
Generic: 70 mg
Granules, Oral:
Epsom Salt: (454 g, 1810 g, 1816 g)
Solution, Injection:
Generic: 40 mg/mL (50 mL, 100 mL, 500 mL, 1000 mL); 80 mg/mL (50 mL); 50% (2 mL, 10 mL, 20 mL, 50
mL)
Solution, Intravenous:
Generic: 10 mg/mL (100 mL); 20 mg/mL (500 mL)
Dosage Forms Considerations
1 g of magnesium sulfate = elemental magnesium 98.6 mg = magnesium 8.12 mEq = magnesium 4.06 mmol
Magnesium sulfate 1% [10 mg/mL] in Dextrose 5% injection is equivalent to elemental magnesium 0.081 mEq/mL.
Magnesium sulfate 2% [20 mg/mL] in Dextrose 5% injection is equivalent to elemental magnesium 0.162 mEq/mL.
Magnesium sulfate 4% [40 mg/mL] in Water injection is equivalent to elemental magnesium 0.325 mEq/mL.
Magnesium sulfate 8% [80 mg/mL] in Water injection is equivalent to elemental magnesium 0.65 mEq/mL.
Magnesium sulfate 50% injection is equivalent to elemental magnesium 4 mEq/mL.
Generic Equivalent Available: U.S. Yes
Administration
Injection: May be administered I.M. or I.V.
I.M.: Must be diluted prior to administration for children (Adults: 25% or 50% concentration; Children: 20%
diluted solution)
I.V.: Must be diluted to a 20% solution for I.V. infusion and may be administered I.V. push, IVPB, or
continuous I.V. infusion. When giving I.V. push, must dilute first and should generally not be given any
faster than 150 mg/minute; may administer over 1-2 minutes in patients with persistent pulseless VT or
VF with known hypomagnesemia (Dager, 2006). ACLS guidelines recommend administration over 15
minutes in patients with torsade de pointes (ACLS, 2010). In patients not in cardiac arrest, hypotension
and asystole may occur with rapid administration.
Maximal rate of infusion: Up to 50% of an I.V. dose may be eliminated in the urine, therefore, slower
administration may improve retention. If severely symptomatic, may administer 4 g over 4-5 minutes. For
doses <6 g, infuse over 8-12 hours and for larger doses infuse over 24 hours if patient asymptomatic
(Kraft, 2005).
Oral: When used as a laxative, the patient should drink a full 8 ounces of liquid following each dose. Lemon juice
may be added to the initial solution to improve the taste.
Topical: May dissolve granules to prepare a solution for use as a soaking aid or as a compress. To make a
compress, use a towel to apply as a wet dressing.
Compatibility Stable in D W, D W, D / NS, D NS, LR, NS, R; incompatible with fat emulsion 10%.
Y-site administration: Compatible: Acyclovir, aldesleukin, amifostine, amikacin, ampicillin, aztreonam,
bivalirudin, caspofungin, cefazolin, cefotaxime, cefoxitin, chloramphenicol, cisatracurium, clindamycin,
clonidine, dexmedetomidine, dobutamine, docetaxel, doripenem, doxorubicin liposome, doxycycline,
enalaprilat, erythromycin lactobionate, esmolol, etoposide phosphate, famotidine, fenoldopam, fludarabine,
furosemide, gallium nitrate, gentamicin, granisetron, heparin, hetastarch in lactate electrolyte injection
(Hextend), hydrocortisone sodium succinate, hydromorphone, idarubicin, insulin (regular), kanamycin,
labetalol, levofloxacin, linezolid, meperidine, metronidazole, micafungin, milrinone, minocycline, morphine,
nafcillin, nicardipine, nitroprusside, ondansetron, oxacillin, oxaliplatin, paclitaxel, pancuronium, penicillin G
potassium, piperacillin, piperacillin/tazobactam, potassium chloride, propofol, remifentanil, sargramostim,
telavancin, thiotepa, tobramycin, trimethoprim/sulfamethoxazole, vancomycin, vitamin B complex with C.
Incompatible: Amphotericin B cholesteryl sulfate complex, cefepime, drotrecogin alfa. Variable (consult
5 10 5
1
4 5
detailed reference): Amiodarone, amphotericin B, ciprofloxacin, cyclosporine, pantoprazole.
Compatibility in syringe: Compatible: Dimenhydrinate, metoclopramide. Incompatible: Calcium chloride,
pantoprazole, phytonadione. Variable (consult detailed reference): Folic acid, hydrocortisone sodium
succinate, potassium phosphate.
Use
Treatment and prevention of hypomagnesemia; prevention and treatment of seizures in severe pre-eclampsia or
eclampsia, pediatric acute nephritis; treatment of cardiac arrhythmias (VT/VF) caused by hypomagnesemia
OTC labeling: Soaking aid for minor cuts and bruises; laxative for the relief of occasional constipation
Use - Unlabeled Asthma exacerbation (life-threatening) unresponsive to 1 hour intensive conventional
treatment; torsade de pointes or VF/pulseless VT associated with torsade de pointes
Medication Safety Issues
Sound-alike/look-alike issues:
Magnesium sulfate may be confused with manganese sulfate, morphine sulfate
MgSO is an error-prone abbreviation (mistaken as morphine sulfate)
High alert medication:
The Institute for Safe Medication Practices (ISMP) includes this medication (I.V. formulation) among its list of
drugs which have a heightened risk of causing significant patient harm when used in error.
Adverse Reactions Significant Adverse effects on neuromuscular function may occur at lower
concentrations in patients with neuromuscular disease (eg, myasthenia gravis).
Frequency not defined:
Cardiovascular: Flushing (I.V.; dose related), hypotension (I.V.; rate related), vasodilation (I.V.; rate related)
Endocrine & metabolic: Hypermagnesemia
Contraindications Hypersensitivity to any component of the formulation; heart block; myocardial damage;
I.V. use for pre-eclampsia/eclampsia during the 2 hours prior to delivery
Warnings/Precautions
Disease-related concerns:
Neuromuscular disease: Use with extreme caution in patients with myasthenia gravis or other neuromuscular
disease.
Renal impairment: Use with caution in patients with renal impairment; accumulation of magnesium may lead
to magnesium intoxication.
Special populations:
Obstetrics: Vigilant monitoring and safe administration techniques (ISMP, 2005) recommended to avoid
potential for errors resulting in toxicity. Monitor mother and fetus closely. Use longer than 5-7 days may
cause adverse fetal events.
4
(For additional information: Launch Lexi-Interact Drug Interactions Program)
Dosage form specific issues:
Aluminum: Solutions may contain aluminum; toxic concentrations may occur following prolonged
administration in premature neonates or patients with renal impairment.
Other warnings/precautions:
Appropriate use: Irregular/Polymorphic VT (with normal baseline QT interval): Unlikely to effectively terminate
(Neumar, 2010).
Electrolyte abnormalities: Concurrent hypokalemia or hypocalcemia can accompany a magnesium deficit.
Hypomagnesemia is frequently associated with hypokalemia and requires correction in order to normalize
potassium.
Parenteral administration: Magnesium toxicity can lead to fatal cardiovascular arrest and/or respiratory
paralysis.
Self-medication (OTC Use): When used as a soaking aid, patients should not use if there is evidence of
infection or prompt relief is not obtained. When used as a laxative, patients should consult a healthcare
provider prior to use if they have: kidney disease; are on a magnesium-restricted diet; have abdominal
pain, nausea, or vomiting; change in bowel habits lasting >2 weeks; have already used a laxative for >1
week.
Metabolism/Transport Effects None known.
Drug Interactions
Alfacalcidol: May increase the serum concentration of Magnesium Salts. Risk D: Consider therapy modification
Bisphosphonate Derivatives: Magnesium Salts may decrease the serum concentration of Bisphosphonate
Derivatives. Management: Avoid administration of oral magnesium salts within: 2 hours before or after
tiludronate/clodronate/etidronate; 60 minutes after oral ibandronate; or 30 minutes after
alendronate/risedronate. Exceptions: Pamidronate; Zoledronic Acid. Risk D: Consider therapy modification
Calcitriol: May increase the serum concentration of Magnesium Salts. Risk D: Consider therapy modification
Calcium Channel Blockers: May enhance the adverse/toxic effect of Magnesium Salts. Magnesium Salts may
enhance the hypotensive effect of Calcium Channel Blockers. Risk C: Monitor therapy
Calcium Polystyrene Sulfonate: Laxatives may enhance the adverse/toxic effect of Calcium Polystyrene Sulfonate.
More specifically, concomitant use of calcium polystyrene sulfonate with magnesium-containing laxatives may
result in metabolic alkalosis or with sorbitol may result in intestinal necrosis. Management: Avoid concomitant
use of calcium polystyrene sulfonate (rectal or oral) and magnesium-containing laxatives or sorbitol. Risk X:
Avoid combination
CNS Depressants: Magnesium Sulfate may enhance the CNS depressant effect of CNS Depressants. Risk C:
Monitor therapy
Deferiprone: Magnesium Salts may decrease the serum concentration of Deferiprone. Management: Separate
administration of deferiprone and oral medications or supplements that contain polyvalent cations by at least 4
hours. Risk D: Consider therapy modification
Dolutegravir: Magnesium Salts may decrease the serum concentration of Dolutegravir. Management: Administer
dolutegravir at least 2 hours before or 6 hours after oral magnesium salts. Risk D: Consider therapy
modification
Eltrombopag: Magnesium Salts may decrease the serum concentration of Eltrombopag. Management: Separate
administration of eltrombopag and any polyvalent cation (e.g., magnesium-containing products) by at least 4
hours. Risk D: Consider therapy modification
Gabapentin: Magnesium Salts may enhance the CNS depressant effect of Gabapentin. Specifically, high dose
intravenous/epidural magnesium sulfate may enhance the CNS depressant effects of gabapentin. Magnesium
Salts may decrease the serum concentration of Gabapentin. Management: Administer gabapentin at least 2
hours after oral magnesium salts administration. Monitor patients closely for evidence of reduced response to
gabapentin therapy. Monitor for CNS depression if high dose IV/epidural magnesium sulfate is used. Risk D:
Consider therapy modification
Ketorolac (Nasal): May diminish the therapeutic effect of Anticonvulsants. Risk C: Monitor therapy
Ketorolac (Systemic): May diminish the therapeutic effect of Anticonvulsants. Risk C: Monitor therapy
Mefloquine: May diminish the therapeutic effect of Anticonvulsants. Mefloquine may decrease the serum
concentration of Anticonvulsants. Management: Mefloquine is contraindicated for malaria prophylaxis in
persons with a history of convulsions. Monitor anticonvulsant concentrations and treatment response closely
with concurrent use. Risk D: Consider therapy modification
Multivitamins/Fluoride (with ADE): Magnesium Salts may decrease the serum concentration of
Multivitamins/Fluoride (with ADE). Specifically, magnesium salts may decrease fluoride absorption.
Management: To avoid this potential interaction separate the administration of magnesium salts from
administration of a fluoride-containing product by at least 1 hour. Risk D: Consider therapy modification
Mycophenolate: Magnesium Salts may decrease the serum concentration of Mycophenolate. Management:
Separate doses of mycophenolate and oral magnesium salts. Monitor for reduced effects of mycophenolate if
taken concomitant with oral magnesium salts. Risk D: Consider therapy modification
Neuromuscular-Blocking Agents: Magnesium Salts may enhance the neuromuscular-blocking effect of
Neuromuscular-Blocking Agents. Risk C: Monitor therapy
Orlistat: May decrease the serum concentration of Anticonvulsants. Risk C: Monitor therapy
Phosphate Supplements: Magnesium Salts may decrease the serum concentration of Phosphate Supplements.
Management: This applies only to oral phosphate and magnesium administration. Administer oral phosphate
supplements at least 1 hour before, or 2 hours after, oral magnesium salt administration. Exceptions: Sodium
Glycerophosphate Pentahydrate. Risk D: Consider therapy modification
Quinolone Antibiotics: Magnesium Salts may decrease the absorption of Quinolone Antibiotics. Of concern only
with oral administration of both agents. Risk D: Consider therapy modification
Raltegravir: Magnesium Salts may decrease the serum concentration of Raltegravir. Management: Avoid the use of
oral / enteral magnesium salts with raltegravir. No dose separation schedule has been established that
adequately reduces the magnitude of interaction. Risk X: Avoid combination
Sodium Polystyrene Sulfonate: Laxatives may enhance the adverse/toxic effect of Sodium Polystyrene Sulfonate.
More specifically, concomitant use of sodium polystyrene sulfonate with magnesium-containing laxatives may
result in metabolic alkalosis or with sorbitol may result in intestinal necrosis. Management: Avoid concomitant
use of sodium polystyrene sulfonate (rectal or oral) and magnesium-containing laxatives or sorbitol. Risk X:
Avoid combination
Tetracycline Derivatives: Magnesium Salts may decrease the absorption of Tetracycline Derivatives. Only applicable
to oral preparations of each agent. Risk D: Consider therapy modification
Trientine: Magnesium Salts may decrease the serum concentration of Trientine. Trientine may decrease the serum
concentration of Magnesium Salts. Risk D: Consider therapy modification
Food Interactions Increased alcohol intake can deplete magnesium stores (IOM, 1997).
Pregnancy Risk Factor D (show table)
Pregnancy Implications Magnesium crosses the placenta; serum concentrations in the fetus are similar
to those in the mother (Idama, 1998; Osada, 2002). Continuous maternal use for >5-7 days (in doses such as
those used for preterm labor, an off-label use) may cause fetal hypocalcemia and bone abnormalities, as well as
fractures in the neonate. Magnesium sulfate injection is used for the prevention and treatment of seizures in
pregnant or postpartum women with severe pre-eclampsia or eclampsia (ACOG, 2013). Magnesium sulfate may
also be used prior to early preterm delivery to reduce the risk of cerebral palsy (ACOG, 2010; Reeves, 2011).
Tocolytics may be used for the short-term (48 hour) prolongation of pregnancy to allow for the administration of
antenatal steroids and should not be used prior to fetal viability or when the risks of use to the fetus or mother are
greater than the risk of preterm birth; maintenance therapy with tocolytics is ineffective and not recommended.
Magnesium sulfate injection may be used in conjunction with tocolytics for neuroprotection (it is not preferred for
use as a tocolytic); however, an increased risk of maternal complications may be observed when used in
combination with some tocolytic agents (ACOG, 2012).
Lactation Enters breast milk/use caution
Breast-Feeding Considerations Magnesium is found in breast milk; concentrations remain constant
during the first year of lactation and are not influenced by dietary intake under normal conditions. Magnesium
requirements are the same in lactating and nonlactating females (IOM, 1997). When magnesium sulfate is used in
the intrapartum management of eclampsia, breast milk concentrations are generally increased for only ~24 hours
after the end of treatment (Idama, 1998). The manufacturer recommends that caution be used if administered to
nursing women.
Dietary Considerations Whole grains, legumes and dark-green leafy vegetables are dietary sources of
magnesium (IOM, 1997).
Pricing: U.S.
Solution (Magnesium Sulfate Injection)
40 mg/mL (100 mL): $7.67
50% (10 mL): $1.60
Disclaimer: The pricing data provide a representative AWP and/or AAWP price from a single manufacturer of the
brand and/or generic product, respectively. The pricing data should be used for benchmarking purposes only, and
as such should not be used to set or adjudicate any prices for reimbursement or purchasing functions. Pricing data
is updated monthly.
Monitoring Parameters
I.V.: Rapid administration: ECG monitoring, vital signs, deep tendon reflexes; magnesium concentrations if frequent
or prolonged dosing required particularly in patients with renal dysfunction, calcium, and potassium
concentrations; renal function
Obstetrics: Patient status including vital signs, oxygen saturation, deep tendon reflexes, level of consciousness,
fetal heart rate, maternal uterine activity.
Reference Range Serum magnesium: 1.5-2.5 mg/dL; slightly different ranges are reported by different
laboratories
International Brand Names Cholal modificado (MX); Inj. Magnesii Sulfurici (PL); Kiddi Pharmaton (MX);
Magnesii Sulfas (PL); Magnesii Sulfas Siccatus (PL); Magnesium Sulfuricum (PL); Magunesin (KP); Vivioptal Junior
(MX)
Mechanism of Action When taken orally, magnesium promotes bowel evacuation by causing osmotic
retention of fluid which distends the colon with increased peristaltic activity; parenterally, magnesium decreases
acetylcholine in motor nerve terminals and acts on myocardium by slowing rate of S-A node impulse formation and
prolonging conduction time. Magnesium is necessary for the movement of calcium, sodium, and potassium in and
out of cells, as well as stabilizing excitable membranes.
Intravenous magnesium may improve pulmonary function in patients with asthma; causes relaxation of bronchial
smooth muscle independent of serum magnesium concentration.
Pharmacodynamics/Kinetics
Onset of action: Anticonvulsant: I.M.: 1 hour; I.V.: Immediate
Duration of anticonvulsant activity: I.M.: 3-4 hours; I.V.: 30 minutes
Distribution: Bone (50% to 60%); extracellular fluid (1% to 2%) (IOM, 1997)
Protein binding: 30%, to albumin
Excretion: Urine (as magnesium)
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REFERENCES
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