Drugs affecting calcium balance

3.  About 1000 mg of Ca is ingested per day.  About 200 mg of this is absorbed into the body.  Absorption
occurs in the small intestine, and requires vitamin D  Milk and dairy products-Egg yolk , Fish, beans  Cow’s milk
100mg/100ml  Human milk 30mg/100ml

4. RECOMMENDED DAILY ALLOWANCE (RDA): Adults – 500 mg /day Children - 1200 mg /day Pregnancy & -- 1500
mg /day Lactation SITE : first part and second part of duodenum Calcium absorbed against concentration gradient
and requires energy and a carrier protein.  30 – 80 % of ingested calcium is absorbed  Actively transported out of
the intestinal cells with the help of Ca 2+ dependent ATPase

5. A) Factors favoring calcium absorption • An acidic pH • Presence of sugar acids, organic acids and citric acid •
High protein diet- Lysine and Arginine cause absorption • Presence of vitamin D • Ca : P ratio- A ratio of dietary Ca:
P not more than 2:1 is adequate for optimal absorption, ratio of less than 1:2 reduces absorption • State of health
and intact mucosa- A healthy adult absorbs about 40% of dietary calcium. • PTH (Parathormone) stimulates the
activation of vitamin D, thus indirectly increases absorption of vitamin D 5

6. B) Factors inhibiting absorption of calcium • Alkaline pH • High fat diet- Fatty acids form calcium soaps that can
not be absorbed • Presence of Phytates and oxalates- Insoluble calcium salts are formed • Dietary fiber in excess
inhibits absorption • Excess phosphates, magnesium and iron decrease absorption • Glucocorticoids reduce
intestinal absorption of calcium • Calcitonin reduces calcium absorption indirectly by inhibiting the activation of
vitamin D • Advancing age and intestinal inflammatory disorders inhibit absorption of calcium 6

7. The primary site of storage is our bones (about 1000 grams). Some calcium is stored within cells (endoplasmic
reticulum and mitochondria). Bone is produced by osteoblast cells which produce collagen, which is then
mineralized by calcium and phosphate (hydroxyapatite). Bone is remineralized (broken down) by osteoclasts, which
secrete acid, causing the release of calcium and phosphate into the bloodstream. There is constant exchange of
calcium between bone and blood.

8. The major site of Ca excretion in the body is the kidneys. The rate of Ca loss and reabsorption at the kidney can
be regulated. Regulation of absorption, storage, and excretion of Ca results in maintenance of calcium
homeostasis.

10. The overall action of PTH is to increase plasma Ca2+ levels and decrease plasma phosphate levels.  PTH acts
directly on the bones to stimulate Ca2+ resorption and kidney to stimulate Ca2+ reabsorption in the distal tubule of
the kidney and to inhibit reabosorptioin of phosphate (thereby stimulating its excretion).  PTH also acts indirectly
on intestine by stimulating 1,25-(OH)2-D synthesis.

12. PTH increases 1-hydroxylase activity, increasing production of active form. This increases calcium absorption
from the intestines, increases calcium release from bone, and decreases loss of calcium through the kidney. As a
result, PTH secretion decreases, decreasing 1- hydroxylase activity (negative feedback). Low phosphate
concentrations also increase 1- hydroxylase activity (vitamin D increases phosphate reabsorption from the urine).

13. Cholecalciferol was significantly, more effective than Ergocalciferol to increase serum 5(OH)D Cholecalciferol
should be the preferred drug for severe vitamin D deficiency. Longer half-life of D3 suggests that less frequent
dosing may be needed. Alfacalcidol and Dihydrotachysterol are synthetic prodrug which are rapidly hydroxylated in
liver to calcitriol
14. Cholecalciferol or Ergocalciferol ?  Cholecalciferol was significantly, more effective than Ergocalciferol to
increase serum 25(OH)D (J Clin Endocrinol Meta, 2011; 96: 981–988)  Cholecalciferol should be the preferred
drug for severe vitamin D deficiency. (Endocrine Abstracts 2012; 28:19)  Longer half-life of D3 suggests that less
frequent dosing may be needed. (Mayo Clin Proc. 2010;85(8):752-758)

15. Group Condition Dose Infants and children Prevention of vitamin D deficiency 400 IU/Day* (American academy
of Pediatrics) >1 yr to 12Yrs Vitamin D deficiency 1000 IU-5000 IU/Day for 3 months* (American academy of
Pediatrics) Women Pregnancy & lactation 1500-2000 IU/Day from II trimester* Adults Maintenance 2000 IU/Day or
60 K IU/ Month* Adults VDD 60,000 IU/ Week for 8 Weeks* Recommended Dose of Vitamin D3 Absorption: Well
absorbed from the GI tract. Decreased in patients with decreased fat absorption. Excretion: Mainly in the bile &
faeces with only small amounts appearing in urine. * Recommended by Dr.Michael F. Folick (TheVitamin D
Solution)

Vitamin D Deficiency: Consequences

17. Calcitonin acts to decrease plasma Ca2+ levels. While PTH and vitamin D act to increase plasma Ca2+-- only
calcitonin causes a decrease in plasma Ca2+. Calcitonin is synthesized and secreted by the parafollicular cells of the
thyroid gland. They are distinct from thyroid follicular cells by their large size, pale cytoplasm, and small secretory
granules. Synthetic salmon calcitonin-sc, im

18. CARPOPEDAL SPAM Obstetric hand  Laryngeal stridor  Convulsions  Visceral features like intestinal spasm,
bronchospasm and profuse sweating.

19. CALCIUM LEVEL > 12 mg / dL ▪ Nervous system is depressed ▪ Reflex activities are sluggish ▪ Decreased QT
interval ▪ Lack of appetite

22.  Oral PO4 for serum Ca < 11.5 mg/dL with mild symptoms and no kidney disease  IV saline and diuretic
(furosemide) for more rapid correction for serum Ca < 18 mg/dL  Bisphosphonates or other Ca-lowering drugs for
serum Ca < 18 mg/dL and > 11.5 mg/dL or moderate symptoms 26

23.  CALCIUM CARBONATE  Ca CITRATE  GLYCEROPPHOSPHATE  LACTATE  GLUCONATE 

HEPTAGLUCONATE

24. To correct calcium deficiency Post- menopausal osteoporosis Rickets and osteomalacia Removal of parathyroid
adenoma Chronic kidney disease as phosphate binders Hyper-magnesemia Hyperkalemia Cardiac arrest Placebo-
calcium gluconate

25. Bisphosphonates – I GENERATION-ETIDRONATE, CLODRONATE II GENERATION-ALENDRONATE, PAMIDRONATE,

IBANDRONATE III GENERATION-RISEDRONATE, ZONLENDRONATE, Synthetic pyrophosphate derivative Inhibits
osteoclast mediated bone resorption Phosphorus- oxygen-phosphorus moiety is replaced with stable phosphorus-
carbon-phosphorus moiety BPNs also accelerate the osteoclastic apoptosis after they ingest the bone matrix

26. Non steroidal synthetic agents who have action on estrogen receptor is tissue selective RALOXIFENE-used in
post menopausal osteoporosis Bones- reduces vertebral fractures by 30-50% CALCIMIMETICS-CINACALCET-calcium
sensing receptors on parathyroid gland sense the Ca levels and reduce the PTH secretion 30mg once daily.