Note: Each oral tablet (650 mg) contains 7.7 mEq each of sodium and bicarbonate. Each mL of 8.4% IV product provides 1 mEq/mL each of sodium and bicarbonate. Avoid extravasation; tissue necrosis may occur due to hypertonicity and alkalinity (Ref).
Antacid: Oral: 325 mg to 2 g 1 to 4 times/day.
Cardiac arrest (Ref): IV: Initial: 1 mEq/kg/dose; repeat doses should be guided by arterial blood gases.
Routine use of sodium bicarbonate is not recommended. May be considered in the setting of prolonged cardiac arrest only after adequate alveolar ventilation has been established and effective cardiac compressions. Note: In some cardiac arrest situations (eg, metabolic acidosis, hyperkalemia, or sodium channel blocker [eg, tricyclic antidepressant] overdose), sodium bicarbonate may be beneficial.
Cardiac conduction delays due to sodium channel blockade in overdose (off-label use): Note: The optimal dose has not been established (Ref). Also, the optimal QRS threshold at which to initiate therapy has not been established; some experts recommend initiating therapy if the QRS interval is >100 msec (Ref), whereas others state a threshold of >120 msec (Ref). Consultation with a clinical toxicologist or poison control center is highly recommended.
Initial : IV: 50 to 100 mEq or 1 to 2 mEq/kg over 1 to 2 minutes; repeat as needed to achieve narrowing of the QRS interval while maintaining a blood pH of 7.45 to 7.55. May initiate a continuous infusion following initial bolus therapy (Ref).
Continuous infusion: IV: Following initial bolus therapy, initiate a continuous infusion using sodium bicarbonate (8.4%) 150 mEq in 1 L D5W. Administer at a rate of ~150 mL/hour to maintain a serum pH of 7.45 to 7.55. Avoid fluid overload (Ref).
Hyperkalemia , severe/emergent (adjunctive agent) (off-label use): Note: Practice may vary; refer to institutional protocols.
Hyperkalemia with cardiac arrest: Intermittent bolus: IV: 50 mEq over 5 minutes (Ref).
Hyperkalemia with metabolic acidosis: Note: May consider in patients with persistent severe hyperkalemia and/or ECG changes despite calcium and other therapies to decrease serum potassium, particularly in patients with metabolic acidosis (Ref).
IV: 150 mEq in 1 L of D5W over 2 to 4 hours (Ref).
Metabolic acidosis, acute severe: Note: Must treat underlying cause; the underlying cause and degree of acidosis may result in the need for larger or smaller bicarbonate replacement doses. Consider bicarbonate therapy in patients with either a pH of <7.1 or in patients with severe acute kidney injury and a pH of ≤7.2. In most cases, the initial goal of therapy is to maintain a target pH >7.2 until the primary process causing metabolic acidosis is resolved. In patients with a pH of ≤7.2 and severe acute kidney injury, the initial pH goal is >7.3 (Ref). Optimal dosing, regimens, administration, and monitoring have not been identified; refer to institutional protocols.
Example regimens:
Intermittent therapy: 7.5% or 8.4% sodium bicarbonate: IV: Initial: 89.2 to 100 mEq once over 1 to 2 minutes; reassess pH, serum bicarbonate level, and clinical status every 2 hours. If pH remains below target (~7.2 to 7.3), administer an additional 44.6 to 100 mEq sodium bicarbonate or initiate a continuous infusion (Ref).
Example: 100 mEq of 8.4% sodium bicarbonate once over 1 to 2 minutes, then repeat with 50 to 100 mEq or initiate a continuous infusion if pH remains below target (Ref).
Continuous infusion therapy:
Bicarbonate deficit regimen: Note: Dosing is based on the following bicarbonate deficit formula. This equation provides a very rough estimate of the initial bicarbonate replacement dose; monitor clinical status closely. Some experts prefer intermittent bolus therapy over continuous infusion (Ref).
Continuous infusion: IV: Sodium bicarbonate estimated dose (mEq) = 0.5 × weight (kg) × [goal serum bicarbonate – observed serum bicarbonate (mEq/L)]; generally, goal serum bicarbonate is ~8 to 12 mEq/L (Ref). Note: In the equation above, "0.5 × weight (kg)" represents the estimated bicarbonate Vd.
Note: Administer the calculated amount of bicarbonate (mEq) over several hours (eg, 2 to 4 hours) until pH is ~7.2 to 7.3; reassess pH, serum bicarbonate level, and clinical status every 2 hours, and adjust dose as needed until goals are reached (Ref).
Example: For estimated bicarbonate deficit of 150 mEq, administer sodium bicarbonate [8.4%] 150 mEq in 1 L D5W over 2 to 4 hours, then reassess pH, serum bicarbonate level, and clinical status. Adjust dose if pH remains below target (Ref).
Metabolic acidosis in patients with chronic kidney disease: Oral (off-label): Note: KDIGO guidelines suggest oral replacement when plasma HCO3- concentrations are <22 mEq/L (Ref).
Initial: 15.4 to 23.1 mEq/day in divided doses (eg, 650 mg tablet 2 to 3 times daily); titrate to normal serum bicarbonate concentrations (eg, 23 to 29 mEq/L, although a more targeted range of 24 to 26 mEq/L has been suggested by observational studies (Ref)) or up to 5,850 mg/day; baking soda may be used as an alternative in patients who cannot take tablets (Ref). Avoid exceeding serum bicarbonate concentrations >29 mEq/L since this has been associated with increased mortality in patients with chronic kidney disease (Ref).
Neutralize lidocaine with epinephrine dental anesthetic: Neutralizing additive: Mix 10 parts anesthetic (lidocaine with epinephrine) to 1 part 8.4% sodium bicarbonate.
Add 0.18 mL sodium bicarbonate to 1.8 mL cartridge of lidocaine 2% with epinephrine 1:50,000 or 1:100,000.
Add 2 mL sodium bicarbonate to 20 mL vial of lidocaine 2% with epinephrine 1:100,000.
Add 3 mL sodium bicarbonate to 30 mL vial of lidocaine 2% with epinephrine 1:100,000.
Add 5 mL sodium bicarbonate to 50 mL vial of lidocaine 2% with epinephrine 1:100,000.
Prevention of contrast-induced nephropathy (off-label use): IV infusion: 154 mEq/L sodium bicarbonate in D5W solution: 3 mL/kg/hour for 1 hour immediately before contrast injection, then 1mL/kg/hour during contrast exposure and for 6 hours after procedure (Ref). Some have described a prophylactic strategy based on patient risk for contrast induced nephropathy and procedure type (Ref). Note: In patients at high risk for renal complications, no benefit was seen with IV sodium bicarbonate over IV sodium chloride in one study; therefore, some consider IV sodium chloride as the preferred option due to lower cost and no need for compounding (Ref).
Renal tubular acidosis: Oral:
Distal: 0.5 to 2 mEq/kg/day in 4 to 5 divided doses.
Proximal: Initial: 5 to 10 mEq/kg/day; maintenance: Increase as required to maintain serum bicarbonate in the normal range.
Urine alkalinization: Oral: Initial: 48 mEq (4 g), then 12 to 24 mEq (1 to 2 g) every 4 hours; dose should be titrated to desired urinary pH; doses up to 16 g/day (200 mEq) in patients <60 years and 8 g (100 mEq) in patients >60 years. Administration of 48 mEq (4 g) every 8 hours for a total daily dose of 144 mEq (12 g) has also been shown to achieve a urinary pH of at least 7 after a period of 10 hours in one study of healthy volunteers (Ref).
IV (off label): Note: IV administration is recommended for the treatment of specific overdoses (eg, salicylates) (Ref); consultation with a clinical toxicologist or poison control center is highly recommended.
Initial: Note: May consider use of initial bolus doses prior to initiation of a continuous infusion, especially in patients with preexisting acidemia (Ref).
IV: 50 to 100 mEq or 1 to 2 mEq/kg over 1 to 2 minutes; repeat as needed to achieve a urinary pH of 7.5 to 8.5 and a serum pH of 7.45 to 7.55 (Ref). Initiate a continuous infusion following initial bolus therapy (if used) (Ref).
Continuous infusion: IV: Initiate a continuous infusion using sodium bicarbonate (8.4%) 150 mEq in 1 L D5W. Administer at a rate of ~150 mL/hour to maintain a urinary pH of 7.5 to 8.5 and a serum pH of 7.45 to 7.55. Avoid fluid overload (Ref).
The renal dosing recommendations are based upon the best available evidence and clinical expertise. Senior Editorial Team: Bruce Mueller, PharmD, FCCP, FASN, FNKF; Jason A. Roberts, PhD, BPharm (Hons), B App Sc, FSHP, FISAC; Michael Heung, MD, MS.
Note: Contains sodium; use with caution, especially in patients with concomitant hypertension, heart failure, or volume overload (Ref).
Altered kidney function: No dosage adjustment necessary for any degree of kidney dysfunction (Ref).
Hemodialysis, intermittent (thrice weekly): No dosage adjustment necessary (Ref).
Peritoneal dialysis: No dosage adjustment necessary (Ref).
CRRT: No dosage adjustment necessary (Ref).
PIRRT (eg, sustained, low-efficiency diafiltration): No dosage adjustment necessary (Ref).
There are no dosage adjustments provided in the manufacturer's labeling. Use with caution, especially in clinical states associated with edema and sodium retention.
(For additional information see "Sodium bicarbonate: Pediatric drug information")
Note: Dose should be individualized to patient response and target parameters for condition being treated.
Antacid: Note: Chronic antacid therapy not recommended for management of gastroesophageal reflux disease in pediatric patients (Ref).
Children ≥6 years and Adolescents: Powder for solution: Oral: 1/2 teaspoonful in 4 ounces of water/dose; may repeat up to every 2 hours; maximum daily dose: 6 doses/day; do not use maximum dose for longer than 2 weeks.
Cardiac arrest (PALS guidelines): Limited data available: Infants, Children, and Adolescents: IV, Intraosseous: 1 mEq/kg/dose; repeat doses should be guided by arterial blood gases; per the manufacturer, the 4.2% (0.5 mEq/mL) solution may be preferred in infants and children <2 years of age. Note: If intraosseous route is used for administration and is subsequently used to obtain blood samples for acid-base analysis, results will be inaccurate (Ref).
Note: Routine use of sodium bicarbonate (NaHCO3) in cardiac arrest is not recommended. May be considered in the setting of prolonged cardiac arrest only after adequate alveolar ventilation has been established and effective cardiac compressions. Sodium bicarbonate may be indicated in some cardiac arrest situations (eg, hyperkalemia, sodium channel blocker toxicity [eg, tricyclic antidepressant overdose]) (Ref).
Chronic kidney disease (CKD) acidosis: Limited data available: Note: Initiate if serum bicarbonate <22 mEq/L:
Infants, Children, and Adolescents: Oral: Initial dose based on serum bicarbonate levels (see following equation); calculate the deficit to determine dose needed; may divide dose for tolerability; adjust dose to maintain serum bicarbonate within the targeted normal range (eg, children: 22 to 23 mEq/L; adults: 24 to 25 mEq/L); undertreatment should be avoided due to negative effects of acidosis on growth (Ref).
HCO3- (mEq) deficit = 0.5 × weight (kg) × [desired HCO3- (mEq/L) − measured serum HCO3- (mEq/L)]
Hyperkalemia; adjunct: Limited data available; efficacy results variable: Infants, Children, and Adolescents: IV or Intraosseous: 1 to 2 mEq/kg/dose (maximum dose: 50 mEq/dose) has been used to redistribute extracellular potassium into cells; not recommended for routine use for cardiac arrest (Ref).
Metabolic acidosis, acute: Limited data available:
Blood-gas directed dosing (equations): Infants, Children, and Adolescents: IV: These equations provide an estimated replacement dose. The underlying cause and degree of acidosis may result in the need for larger or smaller replacement doses. In most cases, the initial goal of therapy is to target a pH of ~7.2 to prevent overalkalinization (Ref).
HCO3- (mEq) deficit = 0.3 × weight (kg) × base deficit (mEq/L) or
HCO3- (mEq) deficit = 0.3 to 0.5 × weight (kg) × [desired HCO3- (mEq/L) − measured serum HCO3- (mEq/L)]
Weight-directed dosing (if acid-base status is not available): Infants, Children, and Adolescents: IV, Intraosseous: 0.5 to 1 mEq/kg/dose over 5 to 15 minutes; maximum dose: 50 mEq/dose (Ref). Subsequent doses should be based on patient's acid-base status.
Neutralization local anesthetic (lidocaine with epinephrine), dental:
Children and Adolescents: Neutralizing additive: Mix 10 parts anesthetic (lidocaine with epinephrine) to 1 part 8.4% sodium bicarbonate.
Add 0.18 mL 8.4% sodium bicarbonate to 1.8 mL cartridge of lidocaine 2% with epinephrine 1:50,000 or 1:100,000.
Add 2 mL 8.4% sodium bicarbonate to 20 mL vial of lidocaine 2% with epinephrine 1:100,000.
Add 3 mL 8.4% sodium bicarbonate to 30 mL vial of lidocaine 2% with epinephrine 1:100,000.
Add 5 mL 8.4% sodium bicarbonate to 50 mL vial of lidocaine 2% with epinephrine 1:100,000.
Overdose, sodium channel blocker (eg, tricyclic antidepressant [TCA]): Limited data available:
Infants, Children, and Adolescents: IV: 1 to 2 mEq/kg/dose; may repeat in 5 minutes if no response, followed by continuous IV infusion of 150 mEq NaHCO3/L solution to maintain targeted pH. Note: Goal pH of 7.5 to 7.55 is recommended in TCA poisoning with hypotension, widened QRS interval >100 ms, or ventricular arrhythmia (Ref).
Renal tubular acidosis (RTA): Limited data available: Note: Dose should be individualized based on urinary bicarbonate excretion (degree depends on type of RTA), serum bicarbonate, and possibly age-related factors.
Infants, Children, and Adolescents:
Distal; type 1: Oral: Usual dose: 3 to 4 mEq bicarbonate/kg/day in divided doses; titrate to maintain normal electrolyte concentrations; younger patients require more bicarbonate replacement due to acid production during growth; some data suggest infants require a higher dose of 5 to 10 mEq bicarbonate/kg/day and growing children need 4 to 8 mEq bicarbonate/kg/day (Ref).
Proximal, type 2: Oral: Usual dose: 10 to 15 mEq/kg/day in divided doses; titrate as necessary to maintain normal electrolyte concentrations; doses as high as 20 mEq bicarbonate/kg/day have been described (Ref).
Skin protectant; relief of minor irritation: Note: Notify physician if no symptom resolution within 14 days, or if symptoms reappear after an initial resolution.
Children ≥2 years and Adolescents: Topical: Powder for solution (baking soda):
Bath soak: Topical: Dissolve 1 to 2 cups of powder in tub of warm water and soak for 10 to 30 minutes; pat skin dry (do not rub).
Compress or wet dressing: Topical: Mix powder with water; soak clean, soft cloth in mixture and apply cloth loosely to affected area for 15 to 30 minutes; may repeat as needed or as directed by physician.
Paste: Topical: Mix powder with water to form a paste and apply to the affected area of skin as needed.
There are no dosage adjustments provided in the manufacturer's labeling. Use with caution; can cause sodium retention.
There are no dosage adjustments provided in the manufacturer's labeling. Use with caution, especially in clinical states associated with edema and sodium retention.
Refer to adult dosing.
Excipient information presented when available (limited, particularly for generics); consult specific product labeling. [DSC] = Discontinued product
Powder, Oral:
Generic: (1 g, 120 g, 454 g, 500 g, 1000 g, 2500 g, 10000 g, 12000 g, 25000 g, 45000 g)
Solution, Intravenous:
Neut: 4% (5 mL [DSC])
Generic: 4.2% (5 mL, 10 mL); 8.4% (10 mL, 50 mL)
Solution, Intravenous [preservative free]:
Generic: 4.2% (5 mL); 7.5% (50 mL); 8.4% (50 mL)
Tablet, Oral:
Generic: 325 mg, 650 mg
Yes
Sodium bicarbonate solution 4.2% [42 mg/mL] provides 0.5 mEq/mL each of sodium and bicarbonate
Sodium bicarbonate solution 7.5% [75 mg/mL] provides 0.9 mEq/mL each of sodium and bicarbonate
Sodium bicarbonate solution 8.4% [84 mg/mL] provides 1 mEq/mL each of sodium and bicarbonate
Excipient information presented when available (limited, particularly for generics); consult specific product labeling.
Solution, Intravenous:
Generic: 4.2% (10 mL); 7.5% (50 mL); 8.4% (10 mL, 50 mL)
IV: For direct IV infusion in emergencies, administer slowly; for infusion, dilute to a maximum concentration of 0.5 mEq/mL in dextrose solution and infuse over at least 2 hours (maximum rate of administration: 1 mEq/kg/hour).
Vesicant (at concentrations ≥8.4%); ensure proper needle or catheter placement prior to and during IV infusion. Avoid extravasation.
Extravasation management: If extravasation occurs, stop infusion immediately and disconnect (leave needle/cannula in place); gently aspirate extravasated solution (do NOT flush the line); initiate hyaluronidase antidote; remove needle/cannula; apply dry cold compresses (Ref); elevate extremity.
Hyaluronidase: Intradermal or SubQ: Inject a total of 1 to 1.7 mL (15 units/mL) as five separate 0.2 to 0.3 mL injections (using a 25-gauge needle) into area of extravasation at the leading edge in a clockwise manner (Ref).
Oral product should be administered 1 to 3 hours after meals.
Infiltration (dental use; Onpharma): Add specified volume of 8.4% sodium bicarbonate directly with lidocaine and epinephrine injection and mix; use immediately after mixing.
Oral:
Powder for solution (baking soda): Measure dose exactly, mix with adequate amount of water (eg, 1/2 teaspoon powder with 4 ounces of water), allow to dissolve completely prior to administration.
Neutralizing additive (dental use): Add specified volume of 8.4% sodium bicarbonate directly with lidocaine and epinephrine injection and mix; use immediately after mixing.
Parenteral:
Direct IV injection:
Neonates and Infants: Administer 0.5 mEq/mL solution; infusion rate depends upon indication, see dosing (Ref).
Children and Adolescents: Administer 1 mEq/mL solution; infusion rate depends upon indication, see dosing; maximum rate: 10 mEq/minute (Ref).
IV infusion: Infusion time variable based upon indication; may be added to IV fluids for infusion when urgent correction is not needed; for metabolic acidosis, infusions over 4 to 8 hours have been suggested (Ref); in neonates, the maximum rate of administration: 1 mEq/kg/hour (Ref).
Vesicant (at concentrations ≥8.4%); ensure proper needle or catheter placement prior to and during IV infusion. Avoid extravasation. If extravasation occurs, stop infusion immediately and disconnect (leave needle/cannula in place); gently aspirate extravasated solution (do NOT flush the line); initiate hyaluronidase antidote (see "Management of Drug Extravasations" for more details); remove needle/cannula; apply dry cold compresses (Ref); elevate extremity.
Topical: Paste, compress/dressing: Apply to clean affected area.
Management of metabolic acidosis; gastric hyperacidity; alkalinization of the urine; management of overdose of certain drugs, including tricyclic antidepressants and aspirin.
Neutralizing additive (IV use): To reduce the incidence of chemical phlebitis and patient discomfort due to vein irritation at or near the infusion site by raising the pH of IV acid solutions.
Neutralizing additive (dental use): Improves onset of analgesia and reduces injection site pain by adjusting lidocaine with epinephrine solution to a more physiologic pH.
Cardiac conduction delays due to sodium channel blockade in overdose; Contrast-induced nephropathy (prevention); Hyperkalemia, severe/emergent
The following adverse drug reactions and incidences are derived from product labeling unless otherwise specified.
Frequency not defined.
Cardiovascular: Cardiac failure (exacerbation), edema
Central nervous system: Cerebral hemorrhage
Endocrine & metabolic: Acidosis (intracranial), hypernatremia, hypocalcemia, hypokalemia, metabolic alkalosis, milk-alkali syndrome (especially with renal dysfunction)
Gastrointestinal: Abdominal distention, eructation, flatulence (oral administration)
Neuromuscular & skeletal: Tetany
Respiratory: Pulmonary edema
Chloride loss due to vomiting or from continuous GI suction; concomitant use of diuretics known to produce a hypochloremic alkalosis.
Neutralizing additive (dental or IV use): Not for use as a systemic alkalizer.
Concerns related to adverse effects:
• Extravasation: Vesicant (at concentrations ≥8.4%); ensure proper catheter or needle position prior to and during infusion. Avoid extravasation (tissue necrosis may occur due to hypertonicity and alkalinity) (Ong 2020).
Disease-related concerns:
• Cirrhosis: Use with caution in patients with cirrhosis.
• Edema: Use with caution in patients with edema.
• Heart failure: Use with caution in patients with heart failure.
• Peptic ulcer disease: Not to be used in treatment of peptic ulcer disease.
• Renal impairment: Use with caution in patients with renal impairment; may cause sodium retention.
Special populations:
• Older adult: Not the antacid of choice for the elderly because of sodium content and potential for systemic alkalosis.
• Pediatric: Rapid administration in neonates, infants, and children <2 years of age has led to hypernatremia, decreased CSF pressure, and intracranial hemorrhage.
Dosage form specific issues:
• Injection: Use of IV sodium bicarbonate should be reserved for documented severe metabolic acidosis and for severe/emergent hyperkalemia (eg, cardiotoxicity or cardiac arrest). Routine use in cardiac arrest is not recommended.
None known.
Note: Interacting drugs may not be individually listed below if they are part of a group interaction (eg, individual drugs within “CYP3A4 Inducers [Strong]” are NOT listed). For a complete list of drug interactions by individual drug name and detailed management recommendations, use the Lexicomp drug interactions program by clicking on the “Launch drug interactions program” link above.
Acalabrutinib: Antacids may decrease the serum concentration of Acalabrutinib. Management: Separate administration of acalabrutinib capsules from the administration of any antacid by at least 2 hours in order to minimize the potential for a significant interaction. Acalabrutinib tablets are not expected to interact with antacids. Risk D: Consider therapy modification
AcetaZOLAMIDE: May enhance the adverse/toxic effect of Sodium Bicarbonate. Specifically, the risk of renal calculus formation may be increased. Risk C: Monitor therapy
Alpha-/Beta-Agonists (Indirect-Acting): Alkalinizing Agents may increase the serum concentration of Alpha-/Beta-Agonists (Indirect-Acting). Risk C: Monitor therapy
Amantadine: Alkalinizing Agents may increase the serum concentration of Amantadine. Risk C: Monitor therapy
Amphetamines: Alkalinizing Agents may decrease the excretion of Amphetamines. Management: Consider alternatives to using amphetamines and alkalinizing agents in combination. If these agents must be used together, patients should be monitored closely for excessive amphetamine effects. Risk D: Consider therapy modification
Antipsychotic Agents (Phenothiazines): Antacids may decrease the absorption of Antipsychotic Agents (Phenothiazines). Risk C: Monitor therapy
Atazanavir: Antacids may decrease the absorption of Atazanavir. Management: Administer antacids 1 to 2 hours before or 2 hours after atazanavir to minimize the risk of a clinically significant interaction. Risk D: Consider therapy modification
Belumosudil: Antacids may decrease the serum concentration of Belumosudil. Management: Consider separating administration of belumosudil and antacids by 2 hours and monitor for reduced belumosudil efficacy. Risk D: Consider therapy modification
Bisacodyl: Antacids may diminish the therapeutic effect of Bisacodyl. Antacids may cause the delayed-release bisacodyl tablets to release drug prior to reaching the large intestine. Gastric irritation and/or cramps may occur. Management: Antacids should not be used within 1 hour before bisacodyl administration. Risk D: Consider therapy modification
Bismuth Subcitrate: Antacids may diminish the therapeutic effect of Bismuth Subcitrate. Management: Avoid administration of antacids within 30 minutes of bismuth subcitrate (tripotassium bismuth dicitrate) administration. Risk D: Consider therapy modification
Bosutinib: Antacids may decrease the serum concentration of Bosutinib. Management: Administer antacids more than 2 hours before or after bosutinib. Risk D: Consider therapy modification
Bromperidol: Antacids may decrease the absorption of Bromperidol. Risk C: Monitor therapy
Calcium Polystyrene Sulfonate: Antacids may enhance the adverse/toxic effect of Calcium Polystyrene Sulfonate. The combined use of these two agents may result in metabolic alkalosis. Risk C: Monitor therapy
Captopril: Antacids may decrease the serum concentration of Captopril. Risk C: Monitor therapy
Cefditoren: Antacids may decrease the serum concentration of Cefditoren. Risk X: Avoid combination
Cefpodoxime: Antacids may decrease the serum concentration of Cefpodoxime. Risk C: Monitor therapy
Cefuroxime: Antacids may decrease the serum concentration of Cefuroxime. Management: Administer cefuroxime axetil at least 1 hour before or 2 hours after the administration of short-acting antacids. Risk D: Consider therapy modification
Chloroquine: Antacids may decrease the serum concentration of Chloroquine. Management: Separate the administration of antacids and chloroquine by at least 4 hours to minimize any potential negative impact of antacids on chloroquine bioavailability. Risk D: Consider therapy modification
Corticosteroids (Oral): Antacids may decrease the bioavailability of Corticosteroids (Oral). Management: Consider separating doses by 2 or more hours. Budesonide enteric coated tablets could dissolve prematurely if given with drugs that lower gastric acid, with unknown impact on budesonide therapeutic effects. Risk D: Consider therapy modification
Cysteamine (Systemic): Antacids may diminish the therapeutic effect of Cysteamine (Systemic). Risk C: Monitor therapy
Dabigatran Etexilate: Antacids may decrease the serum concentration of Dabigatran Etexilate. Management: Dabigatran etexilate Canadian product labeling recommends avoiding concomitant use with antacids for 24 hours after surgery. In other situations, administer dabigatran etexilate 2 hours prior to antacids. Monitor clinical response to dabigatran therapy. Risk D: Consider therapy modification
Dasatinib: Antacids may decrease the serum concentration of Dasatinib. Management: Simultaneous administration of dasatinib and antacids should be avoided. Administer antacids 2 hours before or 2 hours after dasatinib. Risk D: Consider therapy modification
Delavirdine: Antacids may decrease the serum concentration of Delavirdine. Management: Separate doses of delavirdine and antacids by at least 1 hour. Monitor for decreased delavirdine therapeutic effects with this combination. Risk D: Consider therapy modification
Erlotinib: Antacids may decrease the serum concentration of Erlotinib. Management: Separate the administration of erlotinib and any antacid by several hours in order to minimize the risk of a significant interaction. Risk D: Consider therapy modification
Flecainide: Sodium Bicarbonate may increase the excretion of Flecainide. Sodium Bicarbonate may increase the serum concentration of Flecainide. Risk C: Monitor therapy
Fosinopril: Antacids may decrease the serum concentration of Fosinopril. Management: The US and Canadian fosinopril manufacturer labels recommend separating the doses of antacids and fosinopril by 2 hours. Risk D: Consider therapy modification
Gefitinib: Antacids may decrease the serum concentration of Gefitinib. Management: Administer gefitinib at least 6 hours before or 6 hours after administration of an antacid, and closely monitor clinical response to gefitinib. Risk D: Consider therapy modification
Hyoscyamine: Antacids may decrease the serum concentration of Hyoscyamine. Management: Administer immediate release hyoscyamine before meals and antacids after meals when these agents are given in combination. Risk D: Consider therapy modification
Infigratinib: Antacids may decrease serum concentrations of the active metabolite(s) of Infigratinib. Antacids may decrease the serum concentration of Infigratinib. Management: Avoid coadministration of infigratinib with antacids or other gastric acid-lowering agents. If antacids cannot be avoided, administer infigratinib 2 hours before or after administration of antacids. Risk D: Consider therapy modification
Iron Preparations: Antacids may decrease the absorption of Iron Preparations. Management: No action is likely necessary for the majority of patients who only use antacids intermittently or occasionally. Consider separating doses of oral iron and antacids in patients who require chronic use of both agents and monitor for reduced iron efficacy. Risk D: Consider therapy modification
Isoniazid: Antacids may decrease the absorption of Isoniazid. Risk C: Monitor therapy
Itraconazole: Antacids may decrease the serum concentration of Itraconazole. Antacids may increase the serum concentration of Itraconazole. Management: Administer Sporanox brand itraconazole at least 2 hours before or 2 hours after administration of any antacids. Exposure to Tolsura brand itraconazole may be increased by antacids; consider itraconazole dose reduction. Risk D: Consider therapy modification
Ketoconazole (Systemic): Antacids may decrease the serum concentration of Ketoconazole (Systemic). Management: Administer antacids at least 1 hour prior to, or 2 hours after, ketoconazole. Additionally, administer ketoconazole with an acidic beverage (eg, non-diet cola) and monitor patients closely for signs of inadequate clinical response to ketoconazole. Risk D: Consider therapy modification
Lanthanum: Antacids may diminish the therapeutic effect of Lanthanum. Management: Administer antacid products at least 2 hours before or after lanthanum. Risk D: Consider therapy modification
Ledipasvir: Antacids may decrease the serum concentration of Ledipasvir. Management: Separate the administration of ledipasvir and antacids by 4 hours. Risk D: Consider therapy modification
Levoketoconazole: Antacids may decrease the absorption of Levoketoconazole. Management: Advise patients to take antacids at least 2 hours after taking levoketoconazole. Risk D: Consider therapy modification
Lithium: Sodium Bicarbonate may increase the excretion of Lithium. Risk C: Monitor therapy
Mecamylamine: Alkalinizing Agents may increase the serum concentration of Mecamylamine. Risk C: Monitor therapy
Memantine: Alkalinizing Agents may increase the serum concentration of Memantine. Risk C: Monitor therapy
Mesalamine: Antacids may diminish the therapeutic effect of Mesalamine. Antacid-mediated increases in gastrointestinal pH may cause the premature release of mesalamine from specific sustained-release mesalamine products. Management: Avoid concurrent administration of antacids with the Apriso brand of mesalamine extended-release capsules. The optimal duration of dose separation is unknown. Other mesalamine products do not contain this interaction warning. Risk D: Consider therapy modification
Methenamine: Antacids may diminish the therapeutic effect of Methenamine. Management: Consider avoiding the concomitant use of medications that alkalinize the urine, such as antacids, and methenamine. Monitor for decreased therapeutic effects of methenamine if used concomitant with antacids. Risk D: Consider therapy modification
Multivitamins/Minerals (with ADEK, Folate, Iron): Antacids may decrease the serum concentration of Multivitamins/Minerals (with ADEK, Folate, Iron). Specifically, antacids may decrease the absorption of orally administered iron. Management: Separate dosing of oral iron-containing multivitamins and antacids by as much time as possible to minimize impact of this interaction. Monitor for decreased therapeutic efficacy of oral iron preparations during coadministration. Risk D: Consider therapy modification
Naproxen: Antacids may decrease the absorption of Naproxen. Risk X: Avoid combination
Neratinib: Antacids may decrease the serum concentration of Neratinib. Specifically, antacids may reduce neratinib absorption. Management: Separate the administration of neratinib and antacids by giving neratinib at least 3 hours after the antacid. Risk D: Consider therapy modification
Nilotinib: Antacids may decrease the serum concentration of Nilotinib. Management: Separate the administration of nilotinib and any antacid by at least 2 hours whenever possible in order to minimize the risk of a significant interaction. Risk D: Consider therapy modification
Octreotide: Antacids may decrease the serum concentration of Octreotide. Risk C: Monitor therapy
PAZOPanib: Antacids may decrease the serum concentration of PAZOPanib. Management: Avoid the use of antacids in combination with pazopanib whenever possible. Separate doses by several hours if antacid treatment is considered necessary. The impact of dose separation has not been investigated. Risk D: Consider therapy modification
Pexidartinib: Antacids may decrease the serum concentration of Pexidartinib. Management: Administer pexidartinib at least 2 hours before or 2 hours after antacids. Risk D: Consider therapy modification
Phosphate Supplements: Antacids may decrease the absorption of Phosphate Supplements. Management: This applies only to oral phosphate administration. Separating administration of oral phosphate supplements from antacid administration by as long as possible may minimize the interaction. Risk D: Consider therapy modification
Potassium Phosphate: Antacids may decrease the serum concentration of Potassium Phosphate. Management: Consider separating administration of antacids and oral potassium phosphate by at least 2 hours to decrease risk of a significant interaction. Risk D: Consider therapy modification
QuiNIDine: Antacids may decrease the excretion of QuiNIDine. Risk C: Monitor therapy
QuiNINE: Alkalinizing Agents may increase the serum concentration of QuiNINE. Risk C: Monitor therapy
Rilpivirine: Antacids may decrease the serum concentration of Rilpivirine. Management: Administer antacids at least 2 hours before or 4 hours after oral rilpivirine when used with most rilpivirine products. However, administer antacids at least 6 hours before or 4 hours after the rilpivirine/dolutegravir combination product. Risk D: Consider therapy modification
Riociguat: Antacids may decrease the serum concentration of Riociguat. Management: Separate the administration of antacids and riociguat by at least 1 hour in order to minimize any potential interaction. Monitor clinical response to riociguat more closely in patients using this combination. Risk D: Consider therapy modification
Rosuvastatin: Antacids may decrease the serum concentration of Rosuvastatin. Risk C: Monitor therapy
Selpercatinib: Antacids may decrease the serum concentration of Selpercatinib. Management: Coadministration of selpercatinib and antacids should be avoided. If coadministration cannot be avoided, selpercatinib should be administered 2 hours before or 2 hours after antacids. Risk D: Consider therapy modification
Sodium Polystyrene Sulfonate: Antacids may enhance the adverse/toxic effect of Sodium Polystyrene Sulfonate. Specifically, the risk of metabolic alkalosis may be increased. Antacids may diminish the therapeutic effect of Sodium Polystyrene Sulfonate. Risk C: Monitor therapy
Sotalol: Antacids may decrease the serum concentration of Sotalol. Management: Avoid simultaneous administration of sotalol and antacids. Administer antacids 2 hours after sotalol. Risk D: Consider therapy modification
Sotorasib: Antacids may decrease the serum concentration of Sotorasib. Management: Avoid coadministration of sotorasib and antacids. If use of a gastric acid suppressing medication cannot be avoided, administer sotorasib 4 hours before or 10 hours after oral antacid administration. Risk D: Consider therapy modification
Sulpiride: Antacids may decrease the serum concentration of Sulpiride. Management: Separate administration of antacids and sulpiride by at least 2 hours in order to minimize the impact of antacids on sulpiride absorption. Risk D: Consider therapy modification
Tetracyclines: Antacids may decrease the absorption of Tetracyclines. Management: Separate administration of antacids and oral tetracycline derivatives by several hours when possible to minimize the extent of this potential interaction. Monitor for decreased therapeutic effects of tetracyclines. Risk D: Consider therapy modification
Velpatasvir: Antacids may decrease the serum concentration of Velpatasvir. Management: Separate administration of velpatasvir and antacids by at least 4 hours. Risk D: Consider therapy modification
Medications used for the treatment of cardiac arrest in pregnancy are the same as in the nonpregnant woman. Doses and indications should follow current Advanced Cardiovascular Life Support guidelines. Appropriate medications should not be withheld due to concerns of fetal teratogenicity (Campbell 2009; Jeejeebhoy [AHA] 2015). Antacids containing sodium bicarbonate should not be used during pregnancy due to their potential to cause metabolic alkalosis and fluid overload in the mother and fetus (Body 2016; Dağlı 2017; Gomes 2018; Thélin 2020).
Sodium is found in breast milk (IOM 2004).
Some products may contain sodium. Oral product should be taken 1 to 3 hours after meals.
Serum electrolytes (including bicarbonate, potassium, sodium, calcium), urinary pH, arterial blood gases (if indicated).
Dissociates to provide bicarbonate ion which neutralizes hydrogen ion concentration and raises blood and urinary pH
Neutralizing additive (dental use): Increases pH of lidocaine and epinephrine solution to improve tolerability and increase tissue uptake
Onset of action: Oral: 15 minutes; IV: Rapid
Duration: Oral: 1 to 3 hours; IV: 8 to 10 minutes
Absorption: Oral: Well absorbed
Excretion: Urine (<1%)
Solution (Sodium Bicarbonate Intravenous)
4.2% (per mL): $1.86 - $4.95
7.5% (per mL): $0.43
8.4% (per mL): $0.15 - $0.52
Tablets (Sodium Bicarbonate Oral)
325 mg (per each): $0.01 - $0.05
650 mg (per each): $0.01 - $0.05
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