Usage
- Disodium hydrogen citrate is prescribed for conditions requiring alkalinization of urine, such as renal tubular acidosis, uric acid and cysteine kidney stones, and urinary tract infections (UTIs). It is also used to manage gout and relieve the discomfort of painful or difficult urination. It can also be used to counteract metabolic acidosis in acute infections and dehydration. It may be used as an adjuvant to enhance the efficacy of certain antibiotics like sulphonamides and fluroquinolones in alkaline pH.
- Pharmacological Classification: Systemic alkalizer, urinary alkalinizer.
- Mechanism of Action: Disodium hydrogen citrate is metabolized to bicarbonate, which increases urinary pH by increasing the excretion of free bicarbonate ions. This rise in pH increases the solubility of cystine and ionizes uric acid to the more soluble urate ion, preventing stone formation and promoting excretion of uric acid. The alkalinization of urine can also inhibit bacterial growth, potentially aiding in UTI management.
Alternate Names
- Sodium Citrate Dihydrate
- Brand Names: Citralka, Alkarate, Systal, Alkasol, Alkasol-P, Alkanil, Alkadoz, Alkacitral.
How It Works
- Pharmacodynamics: Disodium hydrogen citrate increases urinary pH without causing systemic alkalosis at recommended doses. It enhances the solubility of cystine and uric acid in urine, preventing stone formation. It can also alleviate symptoms associated with UTIs and metabolic acidosis by reducing acidity.
- Pharmacokinetics: It is readily absorbed after oral administration and metabolized to sodium bicarbonate. Oxidation is virtually complete, with less than 5% of citrate excreted unchanged in the urine. It is primarily eliminated through renal excretion.
- Mode of Action: It primarily works by increasing the excretion of free bicarbonate ions in the urine, thus raising urinary pH and creating an environment less conducive to the formation of uric acid and cystine stones.
- Elimination Pathways: Primarily renal excretion of bicarbonate.
Dosage
Standard Dosage
Adults:
- 15-30 ml, two to three times daily, dissolved in water. Other guidelines suggest 30 ml four times daily. Dosage varies depending on formulation strength and indication.
Children:
- 6-12 years: 10-15 ml, three to four times daily, taken in water or milk.
- <7 years: 2 ml, three times a day.
- 7-12 years: 5 ml, three times a day.
- Pediatric dosages should be determined with caution, and the medication should be used with care in infants.
Special Cases:
- Elderly Patients: Dosage adjustments may be necessary based on renal function and overall health.
- Patients with Renal Impairment: Contraindicated in severe renal impairment (oliguria, azotemia, anuria). Use with caution in mild to moderate renal impairment, with close monitoring of electrolytes.
- Patients with Hepatic Dysfunction: Use with caution. Monitor calcium levels due to potential risk of hypocalcemia.
- Patients with Comorbid Conditions: Use with caution in patients with hypertension, edema, heart failure, or those on a sodium-restricted diet due to the sodium content. Monitor potassium levels, especially in patients on potassium-depleting diuretics.
Clinical Use Cases
Disodium hydrogen citrate is not typically used in clinical settings like intubation, surgical procedures, mechanical ventilation, or the ICU for emergency situations. Its primary role is in managing conditions requiring urine alkalinization. Regional anesthesia with citrate anticoagulation is used in continuous renal replacement therapy (CRRT) but is a different clinical application than oral disodium hydrogen citrate discussed in this document.
Dosage Adjustments
Adjustments should be made based on patient response, renal and hepatic function, and electrolyte levels.
Side Effects
Common Side Effects:
- Stomach cramps, flatulence, diarrhea, mild diuresis, tiredness.
Rare but Serious Side Effects:
- Hypokalemia, metabolic alkalosis, GI ulceration, mood swings, anxiety, dyspnea. Severe allergic reactions (rash, itching, swelling, severe dizziness, trouble breathing) require immediate medical attention.
Long-Term Effects:
Chronic complications from prolonged use are not well documented, but potential electrolyte imbalances should be monitored.
Adverse Drug Reactions (ADR):
Severe allergic reactions, signs of kidney problems (changes in urine output), and severe stomach pain require immediate intervention.
Contraindications
- Severe renal impairment, untreated Addison’s disease, acute dehydration, heat cramps, severe myocardial damage, hypersensitivity to any component, hypernatremia, hyperkalemia, and low blood calcium levels. It is also contraindicated in conditions where sodium salts are restricted (e.g., hypertension, edema). Caution is advised in patients with congestive heart failure and those on sodium-restricted diets.
Drug Interactions
- May increase the half-life of quinidine, amphetamines, ephedrine, and pseudoephedrine. Enhances elimination of salicylates and barbiturates. Additive sodium retention with corticosteroids. Potentiates renal excretion of tetracyclines. May cause hypochloremic alkalosis with potassium-depleting diuretics.
Pregnancy and Breastfeeding
- Safety during pregnancy and breastfeeding has not been established. Use only if benefits outweigh potential risks.
Drug Profile Summary
- Mechanism of Action: Increases urinary pH by increasing bicarbonate excretion.
- Side Effects: Stomach cramps, flatulence, diarrhea, electrolyte imbalances (hypokalemia, metabolic alkalosis).
- Contraindications: Severe renal impairment, untreated Addison’s disease, acute dehydration.
- Drug Interactions: Quinidine, amphetamines, corticosteroids, tetracyclines, potassium-depleting diuretics.
- Pregnancy & Breastfeeding: Safety not established.
- Dosage: Adults: 15-30 ml bid-tid. Children: Dose varies by age; use with caution.
- Monitoring Parameters: Serum electrolytes (sodium, potassium, calcium, bicarbonate), renal function, blood pressure.
Popular Combinations
- Often used with antibiotics (sulfonamides, fluoroquinolones) in UTIs.
Precautions
- General Precautions: Monitor renal function and electrolyte levels, particularly in patients with comorbidities.
- Specific Populations: Use with caution in pregnancy, breastfeeding, children, and the elderly.
- Lifestyle Considerations: Alcohol interaction not specifically documented, but caution is advised.
FAQs (Frequently Asked Questions)
Q1: What is the recommended dosage for Disodium Hydrogen Citrate?
A: Adults: Typically 15-30 ml two to three times daily, dissolved in water. Children’s dosages vary by age and should be determined with caution.
Q2: How does Disodium Hydrogen Citrate work in the body?
A: It’s metabolized to bicarbonate, which increases the pH of urine, making it less acidic.
Q3: What are the primary uses of Disodium Hydrogen Citrate?
A: Renal tubular acidosis, prevention of uric acid and cystine stones, symptomatic relief in UTIs, and gout management.
Q4: What are the common side effects of Disodium Hydrogen Citrate?
A: Stomach cramps, flatulence, and diarrhea are common. Less commonly, electrolyte imbalances can occur.
Q5: Who should avoid taking Disodium Hydrogen Citrate?
A: Patients with severe renal impairment, untreated Addison’s disease, acute dehydration, severe heart conditions, and those on sodium-restricted diets.
Q6: Are there any drug interactions I should be aware of with Disodium Hydrogen Citrate?
A: Yes, it can interact with certain antibiotics, corticosteroids, and other medications. Consult the drug interaction section for details.
Q7: Can Disodium Hydrogen Citrate be used during pregnancy or breastfeeding?
A: Safety hasn’t been established. Use only if benefits outweigh potential risks. Consult a doctor.
Q8: What are the signs of an overdose of Disodium Hydrogen Citrate?
A: Metabolic alkalosis, nausea, vomiting, diarrhea, edema, hypernoia, and convulsions. Seek immediate medical attention if these occur.
Q9: How should I store Disodium Hydrogen Citrate?
A: Store at room temperature, away from direct sunlight and moisture, and out of the reach of children.
Q10: Is disodium hydrogen citrate the same as citric acid?
A: No. Disodium hydrogen citrate is a sodium salt of citric acid. While related, they are chemically distinct compounds with different properties and clinical uses.
