General

sodium citrate and citric acid

Pronunciation:
soe-dee-um sye-trate and sit-rik as-id

Trade Name(s)

• Bicitra
• Oracit
• Shohl's Solution modified

Ther. Class.
antiurolithics
mineral and electrolyte replacements/supplements

Pharm. Class.
alkalinizing agents

Indications

• Management of chronic metabolic acidosis associated with chronic renal insufficiency or renal tubular acidosis.
• Alkalinization of urine.
• Prevention of cystine and urate urinary calculi.
• Prevention of aspiration pneumonitis during surgical procedures.
• Used as a neutralizing buffer.

Action

• Converted to bicarbonate in the body, resulting in increased blood pH.
• As bicarbonate is renally excreted, urine is also alkalinized, increasing the solubility of cystine and uric acid.
• Neutralizes gastric acid.

Therapeutic Effect(s):

• Provision of bicarbonate in metabolic acidosis.
• Alkalinization of the urine.
• Prevention of cystine and urate urinary calculi.
• Prevention of aspiration pneumonitis.

Pharmacokinetics

Absorption: Well absorbed following oral administration.

Distribution: Rapidly and widely distributed.

Metabolism and Excretion: Rapidly oxidized to bicarbonate, which is excreted primarily by the kidneys. Small amounts (<5%) excreted unchanged by the lungs.

Half-life: Unknown.

TIME/ACTION PROFILE (effects on serum pH)

Contraindication/Precautions

Contraindicated in:

• Severe renal impairment;
• Severe sodium restriction;
• HF, untreated hypertension, edema, or toxemia of pregnancy.

Use Cautiously in:

OB:  Lactation: Safety not established

Adverse Reactions/Side Effects

F and E: fluid overload, hypernatremia (severe renal impairment), hypocalcemia, metabolic alkalosis (large doses only)

GI: diarrhea

MS: tetany

* CAPITALS indicate life-threatening.
Underline indicate most frequent.

Interactions

Drug-Drug

• May partially antagonize the effects of  antihypertensives.
• Urinary alkalinization may result in ↓  salicylate  or  barbiturate  levels or ↑ levels of quinidine, flecainide, or  amphetamines.

Route/Dosage

Adjust dosage according to urine pH. Contains 1 mEq sodium and 1 mEq bicarbonate/mL solution

Alkalinizer

PO (Adults): 10–30 mL solution diluted in water 4 times daily.

PO Children: 5–15 mL solution diluted in water 4 times daily.

Antiurolithic

PO (Adults): 10–30 mL solution diluted in water 4 times daily.

Neutralizing Buffer

PO (Adults): 15–30 mL solution diluted in 15–30 mL of water.

Availability

Oral solution: sodium citrate 490 mg and citric acid 640 mg/5 mL, sodium citrate 500 mg and citric acid 300 mg/5 mL, sodium citrate 500 mg and citric acid 334 mg/5 mL

Assessment

• Assess patient for signs of alkalosis (confusion, irritability, paresthesia, tetany, altered breathing pattern) or hypernatremia (edema, weight gain, hypertension, tachycardia, fever, flushed skin, mental irritability) throughout therapy.
• Monitor patients with renal dysfunction for fluid overload (discrepancy in intake and output, weight gain, edema, rales/crackles, and hypertension).

Lab Test Considerations: Prior to and every 4 mo during chronic therapy, monitor hematocrit, hemoglobin, electrolytes, pH, creatinine, urinalysis, and 24-hr urine for citrate.

• Monitor urine pH if used to alkalinize urine.

Potential Diagnoses

• Deficient knowledge, related to medication regimen (Patient/Family/Teaching) 

Implementation

• PO Solution is more palatable if chilled. Administer with 30–90 mL of chilled water. Administer 30 min after meals or as bedtime snack to minimize saline laxative effect.
  • When used as preanesthetic, administer 15–30 mL of sodium citrate with 15–30 mL of chilled water.

Patient/Family Teaching

• Instruct patient to take as directed. Missed doses should be taken within 2 hr. Do not double doses.
• Instruct patients receiving chronic sodium citrate on correct method of monitoring urine pH, maintenance of alkaline urine, and the need to increase fluid intake to 3000 mL/day. When treatment is discontinued, pH begins to fall toward pretreatment levels.
• Advise patients receiving long-term therapy on need to avoid salty foods.

Evaluation/Desired Outcomes

• Correction of metabolic acidosis.
• Maintenance of alkaline urine with resulting decreased stone formation.
• Buffering the pH of gastric secretions, thereby preventing aspiration pneumonitis associated with intubation and anesthesia.