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Medication

Medication Summary

Treatment for hypomagnesemia depends on the degree of deficiency and the patient's clinical symptoms and signs. Therapy can be oral for patients with mild symptoms or intravenous for patients with severe symptoms or those unable to tolerate oral administration. Some patients with hypomagnesemia caused by renal magnesium wasting may benefit from certain diuretics that have magnesium-sparing properties, such as spironolactone and amiloride.

Class Summary

Magnesium can be administered either orally in an oxide or gluconate form or parenterally as a sulfate salt.

Magnesium oxide (Mag-Ox, MagGel 600, Uro-Mag)

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This agent is used for the treatment of magnesium deficiencies or magnesium depletion from malnutrition, restricted diet, alcoholism, or magnesium-depleting drugs.

Magnesium gluconate (Magtrate, Mag-G, Magonate)

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Five hundred milligrams of magnesium gluconate contain 27 mg of elemental magnesium.

Magnesium sulfate

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One gram of magnesium sulfate contains 8.12 mEq of magnesium (98 mg of elemental magnesium).

Class Summary

These medications are used to avoid the loss of potassium in urine.

Amiloride

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Amiloride is a potassium-sparing diuretic that also has some mild hypocalciuric activity. It reduces the magnesium loss caused by thiazides. Amiloride is a pyrazine-carbonyl-guanidine that is chemically unrelated to other known antikaliuretic or diuretic agents. It possesses weak (compared with thiazide diuretics) natriuretic, diuretic, antihypertensive, and hypocalciuric effects.

In some clinical studies, amiloride activity increased the effects of thiazide diuretics. Amiloride is not an aldosterone antagonist, and its effects are observed even in the absence of aldosterone.

Amiloride exerts its potassium-sparing effect through the inhibition of sodium reabsorption at the DCT, the cortical collecting tubule, and the collecting duct. This decreases the net negative potential of the tubular lumen and reduces the secretion, and subsequent excretion, of potassium and hydrogen.

Amiloride usually begins to act within 2 hours after an oral dose. Its effect on electrolyte excretion peaks after between 6-10 hours and lasts about 24 hours. Peak plasma levels are obtained in 3-4 hours, and the drug's plasma half-life ranges from 6-9 hours.

Amiloride is not metabolized by the liver; it is excreted unchanged by the kidneys. About 50% of a dose of amiloride is excreted in urine and 40% is excreted in stool, within 72 hours. The drug has little effect on the GFR or on renal blood flow. Because the liver does not metabolize amiloride HCl, drug accumulation is not anticipated in patients with hepatic dysfunction; however, accumulation can occur if hepatorenal syndrome develops.

Amiloride rarely should be used alone. Used as single agents, potassium-sparing diuretics, including amiloride, result in an increased risk of hyperkalemia (approximately 10% with amiloride). Amiloride should be used alone only when persistent hypokalemia has been documented and only with careful titration of the dose and close monitoring of serum electrolytes.

Spironolactone (Aldactone)

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Spironolactone is a potassium-sparing diuretic that acts on the distal convoluted tubule of the kidney as an aldosterone antagonist.

Triamterene (Dyrenium)

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Triamterene interferes with potassium/sodium exchange (active transport) in the distal tubule, cortical collecting tubule, and collecting duct by inhibiting sodium/potassium adenosine triphosphatase (ATPase). This agent decreases calcium and magnesium excretion.

Questions

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Media Gallery

A: Magnesium reabsorption in the thick ascending limb of the loop of Henle. The driving force for the reabsorption against a concentration gradient is a lumen-positive voltage gradient generated by the reabsorption of NaCl. Terms: FHHNC (familial hypomagnesemia with hypercalciuria and nephrocalcinosis); ADH (autosomal-dominant hypocalcemia); FHH/NSHPT (familial hypomagnesemia/neonatal severe hyperparathyroidism). B: Magnesium reabsorption in the distal convoluted tubule. Active transcellular transport is mediated by an apical entry through a magnesium channel and a basolateral exit, presumably via a Na+/Mg2+ exchange mechanism. Terms: HSH (hypomagnesemia with secondary hypocalcemia); GS (Gitelman syndrome); IDH (isolated dominant hypomagnesemia). Source: Konrad M, Schlingmann KP, Gudermann T: Insights into the molecular nature of magnesium homeostasis. Am J Physiol Renal Physiol 2004; 286: F599-F605.

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Author

Tibor Fulop, MD, PhD, FACP, FASN Professor of Medicine, Department of Medicine, Division of Nephrology, Medical University of South Carolina College of Medicine; Attending Physician, Medical Services, Ralph H Johnson VA Medical Center

Tibor Fulop, MD, PhD, FACP, FASN is a member of the following medical societies: American Academy of Urgent Care Medicine, American College of Physicians, American Society of Hypertension, American Society of Nephrology, International Society for Apheresis, International Society for Hemodialysis, Magyar Orvosi Kamara (Hungarian Chamber of Medicine)

Disclosure: Nothing to disclose.

Coauthor(s)

Mohit Agarwal, MBBS Assistant Professor, Division of Nephrology, Medical College of Wisconsin

Disclosure: Nothing to disclose.

Krishna C Keri, MD, MBBS Fellow in Nephrology and Hypertension, Department of Internal Medicine, Medical College of Wisconsin

Krishna C Keri, MD, MBBS is a member of the following medical societies: American College of Physicians

Disclosure: Nothing to disclose.

Chief Editor

Vecihi Batuman, MD, FASN Professor of Medicine, Section of Nephrology-Hypertension, Deming Department of Medicine, Tulane University School of Medicine

Vecihi Batuman, MD, FASN is a member of the following medical societies: American College of Physicians, American Society of Hypertension, American Society of Nephrology, Southern Society for Clinical Investigation

Disclosure: Nothing to disclose.

Acknowledgements

Mahendra Agraharkar, MD, MBBS, FACP, FASN Clinical Associate Professor of Medicine, Baylor College of Medicine; President and CEO, Space City Associates of Nephrology

Mahendra Agraharkar, MD, MBBS, FACP, FASN is a member of the following medical societies: American College of Physicians, American Society of Nephrology, and National Kidney Foundation

Disclosure: South Shore DaVita Dialysis Center Ownership interest Other

Jeffrey L Arnold, MD, FACEP Chairman, Department of Emergency Medicine, Santa Clara Valley Medical Center

Jeffrey L Arnold, MD, FACEP is a member of the following medical societies: American Academy of Emergency Medicine and American College of Physicians

Disclosure: Nothing to disclose.

Howard A Blumstein, MD, FAAEM Assistant Professor of Surgery, Medical Director, Department of Emergency Medicine, Wake Forest University School of Medicine

Howard A Blumstein, MD, FAAEM is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, American Medical Association, Emergency Medicine Residents Association, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

George P Chrousos, MD, FAAP, MACP, MACE, FRCP(London) Professor and Chair, First Department of Pediatrics, Athens University Medical School, Aghia Sophia Children's Hospital, Greece; UNESCO Chair on Adolescent Health Care, University of Athens, Greece

George P Chrousos, MD, FAAP, MACP, MACE, FRCP(London) is a member of the following medical societies: American Academy of Pediatrics, American College of Endocrinology, American College of Physicians, American Pediatric Society, American Society for Clinical Investigation, Association of American Physicians, Endocrine Society, Pediatric Endocrine Society, and Society for Pediatric Research

Disclosure: Nothing to disclose.

Mark T Fahlen, MD Inc

Mark T Fahlen, MD is a member of the following medical societies: American College of Physicians and Renal Physicians Association

Disclosure: Nothing to disclose.

Enrique Grisoni, MD Associate Professor, Department of Surgery, Division of Pediatric Surgery, University Hospital of Cleveland, Rainbow Babies and Children's Hospital

Disclosure: Nothing to disclose.

Robin R Hemphill, MD, MPH Associate Professor, Director, Quality and Safety, Department of Emergency Medicine, Emory University School of Medicine

Robin R Hemphill, MD, MPH is a member of the following medical societies: American College of Emergency Physicians and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Gunjeet K Kala, MD Clinical Instructor, Division of Pediatric Nephrology, University of Buffalo, State University of New York School of Medicine and Biomedical Sciences, Women and Children's Hospital of Buffalo

Gunjeet K Kala, MD is a member of the following medical societies: American Academy of Pediatrics, American Society of Pediatric Nephrology, and American Society of Pediatric Nephrology

Disclosure: Nothing to disclose.

Stephen Kemp, MD, PhD Professor, Department of Pediatrics, Section of Pediatric Endocrinology, University of Arkansas for Medical Sciences College of Medicine, Arkansas Children's Hospital

Stephen Kemp, MD, PhD is a member of the following medical societies: American Academy of Pediatrics, American Association of Clinical Endocrinologists, American Pediatric Society, Endocrine Society, Phi Beta Kappa, Southern Medical Association, and Southern Society for Pediatric Research

Disclosure: Nothing to disclose.

Nona P Novello, MD Associate Chair, Department of Emergency Medicine, Franklin Square Hospital

Nona P Novello, MD is a member of the following medical societies: American College of Emergency Physicians and Phi Beta Kappa

Disclosure: Nothing to disclose.

Helbert Rondon-Berrios, MD Nephrology Fellow, Renal-Electrolyte Division, University of Pittsburgh Medical Center

Helbert Rondon-Berrios, MD is a member of the following medical societies: American College of Physicians, American Society of Nephrology, National Kidney Foundation, and Renal Physicians Association

Disclosure: Nothing to disclose.

Karl S Roth, MD Professor and Chair, Department of Pediatrics, Creighton University School of Medicine

Karl S Roth, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Pediatrics, American College of Nutrition, American Pediatric Society, American Society for Clinical Nutrition, American Society of Nephrology, Association of American Medical Colleges, Medical Society of Virginia, New York Academy of Sciences, Sigma Xi, Society for Pediatric Research, andSouthern Society for Pediatric Research

Disclosure: Nothing to disclose.

Erik D Schraga, MD Staff Physician, Department of Emergency Medicine, Mills-Peninsula Emergency Medical Associates

Disclosure: Nothing to disclose.

James H Sondheimer, MD, FACP Associate Professor of Medicine, Wayne State University School of Medicine; Medical Director of Hemodialysis, Harper University Hospital at Detroit Medical Center; Medical Director, DaVita Greenview Dialysis (Southfield)

James H Sondheimer, MD, FACP is a member of the following medical societies: American College of Physicians and American Society of Nephrology

Disclosure: Nothing to disclose.

James E Springate, MD Associate Professor of Pediatrics, University of Buffalo, State University of New York School of Medicine and Biomedical Sciences; Attending Physician, Department of Pediatrics, Division of Pediatric Nephrology, Women and Children's Hospital of Buffalo

James E Springate, MD is a member of the following medical societies: American Academy of Pediatrics, American Physiological Society, American Society of Pediatric Nephrology, International Pediatric Transplant Association, and Society for Pediatric Research

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

Christie P Thomas, MBBS, FRCP, FASN, FAHA Professor, Department of Internal Medicine, Division of Nephrology, Medical Director, Kidney and Kidney/Pancreas Transplant Program, University of Iowa Hospitals and Clinics

Christie P Thomas, MBBS, FRCP, FASN, FAHA is a member of the following medical societies: American College of Physicians, American Federation for Medical Research, American Heart Association, American Society of Nephrology, American Society of Transplantation, American Thoracic Society, International Society of Nephrology, and Royal College of Physicians

Disclosure: Genzyme Grant/research funds Other

Mary L Windle, PharmD, Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.

Hypomagnesemia Medication

Medication Summary

Magnesium Salts

Class Summary

Magnesium oxide (Mag-Ox, MagGel 600, Uro-Mag)

Magnesium oxide (Mag-Ox, MagGel 600, Uro-Mag)

Magnesium gluconate (Magtrate, Mag-G, Magonate)