Hypomagnesemia & Hypermagnesemia

Hypomagnesemia & Hypermagnesemia (1 of 3)

HYPOMAGNESEMIA 1 Hospitalized patient presents w/ signs & symptoms of hypomagnesemia

2 DETERMINE UNDERLYING CAUSE & MG LEVELS Mg >0.7 mmol/L Mg <0.7 mmol/L (1.8 mg/dL) (1.8 mg/dL)

3 ALTERNATIVE DIAGNOSIS CLASSIFY SEVERITY Moderate- Mild OF Mg DEPLETION severe

Mg PO REPLACEMENT Mg IV REPLACEMENT

1 SIGNS & SYMPTOMS OF HYPOMAGNESEMIA

• Hypomagnesemia has a serum magnesium concentration of <1.3 mEq/L Neuromuscular CV Metabolic • Muscle weakness • Prolonged PR & QT intervals • Hyperinsulinism • Ataxia & vertigo • Cardiac arrhythmias • Carbohydrate intolerance • Trousseau & Chvostek signs • Atherosclerosis • Carpopedal spasm • Hypocalcemia • Depression, psychosis • Osteoporosis & osteomalacia • Seizures

2 CAUSES OF HYPOMAGNESEMIA

Increased Intestinal Drugs Increased Renal Metabolic Losses • Diuretics Excretion • DM • Vomiting, diarrhea • Aminoglycosides • Volume expansion • Hypoparathyroidism • Prolonged • Cisplatin • Hypercalcemia & • Primary nasogastric suction • Alcohol hypercalciuria hyperparathyroidism • Extensive bowel • Pentamidine • Osmotic diuresis • Primary resection • Ciclosporin • Renal disease w/ Mg aldosteronism • Malabsorption • Amphotericin B wasting • Phosphate depletion syndromes • Renal transplant • Hyperthyroidism • Severe malnutrition • Treatment of • Steatorrhoea ketoacidosis • Acute pancreatitis • Hungry bone • Intestinal fi stula syndrome • Ileitis, colitis

3 SEVERITY OF MAGNESIUM DEPLETION

Mild Hypomagnesemia Moderate-Severe Hypomagnesemia • Patient is© usually asymptomatic MIMS• Patient is usually symptomatic • Serum Mg is usually >0.5 mmol/L (1.2 mg/dL) • Serum Mg is usually <0.5 mmol/L (1.2 mg/dL)

Not all products are available or approved for above use in all countries. Specifi c prescribing information may be found in the latest MIMS.

B1 © MIMS 2019 HYPO- & HYPERMAGNESEMIA • • • • iatrogenic usually &is occurs Rarely • • • • • • &Symptoms Signs • HYPERMAGNESEMIA Lithium w/rhabdomyolysis Acute renal (ARF) failure Untreated ketoacidosis orinfusion antacid, laxative Patient w/renal receiving Mg-containing failure Drowsiness abnormalities ECG arrest &cardiac block Complete heart Bradycardia Hypotension mg/dL) mmol/L (5 Mg unless Usually >2 donotappear concentration magnesium aserum has of>2.2mEq/L Hypermagnesemia Mg <1.3 mmol/L Mg <1.3 ALTERNATIVE DIAGNOSIS © MIMS(3 mg/dL) 1 Not all products are available or approved for above use in all countries. all in use above for approved or available are products all Not SIGNS & SYMPTOMS OF HYPERMAGNESEMIA Hypomagnesemia &Hypermagnesemia(2of3) Specifi c prescribing information may be found in the latest MIMS. latest the in found be may information Specific prescribing 2 CAUSES OF HYPERMAGNESEMIA Hospitalized patient presents w/ signs w/signs patientpresents Hospitalized & symptoms ofhypermagnesemia & symptoms DETERMINE UNDERLYING DETERMINE CAUSE & LEVELS MG DIAGNOSIS B2 1 2 • • • • • • • • • Hypothyroidism Adrenal insuffi (AI) ciency hypercalcemia Familial hypocalciuric Volume depletion Paralysis weakness Muscular tendon reflDisappearance ofdeep exes mental status Depressed respiration &apnea Depressed complications: w/ life-threatening hypermagnesemia In severe therapy Pharmacological • • • Ca (IV) Ca renal failure patients by w/ required be Mg w/low Dialysis bath may contains large amt ofMg Stop preparation that Mg >1.3 mmol/L Mg >1.3 TREATMENT (3 mg/dL) © MIMS 2019 HYPO- & HYPERMAGNESEMIA gluconate Calcium sulfate Magnesium oxide Magnesium lactate Magnesium gluceptate Calcium gluconate Magnesium chloride Calcium Drug Drug Products listed above may not be mentioned in the disease management chart but have been have but chart management disease the in mentioned be not may above listed Products placed here based on indications listed in regional manufacturers’ product information. product manufacturers’ regional in listed indications on based here placed 94510%inj soln 4.5 89 98110%inj soln 8.1 99 9 111 9.9 120 24122%inj soln 4.1 82 948Various oral 4.8 59 10%inj soln 13.6 273 & non-elderly adults w/ normal renal & hepatic function unless otherwise stated. otherwise unless function &hepatic renal w/ normal adults & non-elderly All dosage recommendations are for non-pregnant & non-breastfeeding women, women, &non-breastfeeding non-pregnant for are recommendations dosage All © MIMS mEq/g mg/g mEq/g mg/g Ca Content Ca Content Not all products are available or approved for above use in all countries. all in use above for approved or available are products all Not Hypomagnesemia &Hypermagnesemia(3of3) Specifi c prescribing information may be found in the latest MIMS. latest the in found be may information Specific prescribing Please see the end of this section for the reference list. reference the for section this of end the see Please Dosage Guidelines Ca/mL] (0.45 mEq) [8.9 mg Mg/mL] (4 mEq) [49 mg 50% inj soln Mg/mL] (0.8 mEq) [9.8 mg Ca/mL] (0.9 mEq) [18 mg available strengths are Ca/mL] (1.36 mEq) [27.3 mg Available Available Strength Strength CALCIUM (IV) MAGNESIUM B3 • • • Instructions Special • • Reactions Adverse doses individed 10-28 mEq/day PO hypomagnesemia: Mild doses individed 30-56 mEq/day PO hypomagnesemia: Severe replacement: Oral continuous2 mEq/hrIV infusion Renal insuffi ciency: 8-32mEqIM4-6hrly No IVaccess: continuous 4hrly or8-16mEqIV infusion 4mEq/hrIV by 10minfollowed over 16 mEqIV hypomagnesemia: Severe Parenteral replacement: • • Instructions Special • • • • Reactions Adverse • 100-200 mgelemental 5-10min over IV Ca Smaller continuous abetter may be infusions - are the rapidly by kidneys excreted doses Bolus frequently levels Monitor K&Ca levels ofMg monitoring close upon based Adjust dose diarrhea & watery GI irritation there orallyunless given isrenal impairment which isuncommon when Hypermagnesemia CaCl 0.7-1.8mEq/min nottoexceed slowly Infuse GI eff constipation), (GIirritation, renalects calculi infarction) BP, decreased myocardial arrhythmias, bradycardia, eff inj mayRapid CV IV cause (vasodilation, ects patientsfailure supplemented &those w/Vit D Hypercalcemia which ismore likely inrenal occurs ifextravasation Maygangrene cause - irritating atIrritation isthe inj chloride most site.Ca Antagonizes toxic eff ofMg ects present

option 2 should not be used if metabolic acidosis is acidosis ifmetabolic used shouldnotbe Dosage/Remarks Dosage/Remarks © MIMS 2019