GL/PTC/19.

R1-2014

CHANGI GENERAL HOSPITAL

GUIDELINES ON USE OF
IV MAGNESIUM SULPHATE /
ORAL MAGNESIUM TABLETS
FOR MAGNESIUM REPLACEMENT
These guidelines are approved for use with effect from _8 Jan 2014_
by the Pharmacy and Therapeutics Committee. Original version was created on 13 Jan 2010

Drug Class
Electrolyte

Drug Status
Oral magnesium tablets : General, unrestricted
IV/IM magnesium sulphate : High Alert Medication, unrestricted

Mechanism of Action
Decreases acetylcholine in motor nerve terminals
Acts on myocardium by slowing rate of the sino-atrial node impulse formation and prolonging
conduction time
Necessary for intracellular movement of calcium, sodium and potassium, and for stabilisation of
excitable membranes

Indications
Primary indication:
For treatment and prevention of hypomagnesaemia (normal serum magnesium range: 0.65-0.95
mmol/L)

Secondary indications:
Prevention and treatment of seizures in severe pre-eclampsia or eclampsia (IV magnesium
sulphate only)
Treatment of paediatric acute nephritis
Treatment of hypomagnesaemia-induced cardiac arrhythmias (ventricular tachycardia or
ventricular fibrillation)
Treatment of torsades de pointes

Off-label use:
Asthma exacerbation (life threatening)

Contraindications
Hypersensitivity to components of magnesium formulation
Heart block
Myocardial damage

Precautions
Impaired renal function (creatinine clearance <30 mL/min; accumulation of magnesium may lead
to magnesium toxicity characteristics include cardiovascular arrest and/or respiratory paralysis,
especially in pregnant women)
Neuromuscular disease (especially myasthenia gravis)
Hypokalaemia/hypocalcaemia concurrent with hypomagnesaemia

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Drug Interactions
There are no known interactions where it is recommended to avoid concomitant use.

Interactions impacting on effects of magnesium

The levels/effects of magnesium may be increased by:
Alfacalcidol
Calcitriol
Calcium channel blockers

The levels/effects of magnesium may be reduced by:

Ketorolac
Mefloquine

Interactions caused by the presence of magnesium

Magnesium sulphate may increase the effects/serum concentrations of:
Ethanol (alcohol)
Calcium channel blockers
Central nervous system depressants
Neuromuscular-blocking agents

Magnesium sulphate may reduce the effects/serum concentrations of:

Bisphosphonate derivatives
Mycophenolate
Phosphate supplements (e.g., potassium dihydrogen phosphate)
Quinolone antibiotics
Tetracycline antibiotics/derivatives
Sodium polystyrene sulfonate

Pregnancy Risk Factor

Category D i.e.
There is positive evidence of human foetal risk, but the benefits from use in pregnant women may be
acceptable despite the risk (e.g, if the drug is needed in a life-threatening situation or for a serious
disease for which safer drugs cannot be used or are ineffective).

Continuous maternal use for more than 5-7 days (in doses such as those used for preterm labour, an
off-label use) may cause foetal hypocalcaemia and bone abnormalities, as well as fractures in the
neonate.

Lactation
Magnesium enters breast milk and is to be used with caution in lactation.

Adverse Drug Effects

Cardiovascular : Flushing (dose-related; associated with IV administration)
Hypotension (with rapid rate of administration; associated with IV administration)
Vasodilation (with rapid rate of administration; associated with IV administration)

Gastrointestinal : Diarrhoea

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Recommended Dosing (Adults)

Caution: The chemical formula for magnesium sulphate, i.e., MgSO 4 is an error prone abbreviation
and should not be used (may be mistaken for morphine sulphate)

Serum magnesium is a poor reflection of repletional status as the majority of magnesium is

intracellular
Serum magnesium may be transiently normal for a few hours after a dose is given; therefore, in
patients with normal renal function, aim for consistently high-normal serum levels (0.85-1 mmol/L)
The amount of IV/IM magnesium sulphate prescribed should be individualised
Prescribing of all IV magnesium sulphate should be in g or mmol
Each mL of magnesium sulphate 49.3% inj yields approximately 48 mg of elemental magnesium
2+
(i.e., 2 mmol or 4 mEq of Mg )
Each oral magnesium tablet (magnesium carbonate, magnesium hydroxide & magnesium
acetate) yields 200 mg of elemental magnesium (i.e., 8.3 mmol or 16.6 mEq)

Acute hypomagnesaemia (adults)

Acute hypomagnesaemia should be treated with IV/IM magnesium sulphate (see table below)

Difference between Estimated dose of IV/IM Corresponding dose of

observed and target serum magnesium sulphate IV/IM magnesium
magnesium concentration (mmol) sulphate (g)
(mmol/L)
<0.10 5 1.235
0.11 to 0.3 10 2.47
0.31 to 0.4 15 3.705
0.41 to 0.5 20 4.94
0.51 to 0.6 25 6.175
Estimated dose base on a body weight of approx. 60-65 kg

Chronic hypomagnesaemia (adults)

Chronic hypomagnesaemia is best managed with oral magnesium sulphate
Usual dose : PO 200 mg/day, increasing to 400 mg/day for selected patients

Torsades de pointes (associated with hypomagnesaemia)

I.V: 1-2 g over 15 minutes

Asthma (life-threatening or severe exacerbation after 1 hr of intensive conventional therapy)

Adults : IV 2 g
Children : IV 25-75 mg/kg (maximum: 2 g)

Eclampsia/pre-eclampsia (severe):
IV infusion of 4-6g over 15-20mins followed by continuous IV infusion of 1-2g/hour.

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Reconstitution and Administration

Each ampoule of magnesium sulphate 49.3% inj is pre-reconstituted
Magnesium sulphate inj (up to doses of 20 mmol) should be diluted to a larger volume (preferably
at least 100 mL) before administration via IV infusion; appropriate diluents include normal saline
(sodium chloride 0.9%) and dextrose 5% in water (D5W)
Alternatively, magnesium sulphate inj may be added to IV hydration fluids and administered as
part of the days hydration schedule
In medical emergencies (e.g., torsades de pointes, eclampsia, pre-eclampsia), magnesium
sulphate should be diluted to at least 20mls before administration as a slow IV bolus injection over
15 minutes(as per indications above)

Monitoring
Rapid IV administration: ECG monitoring, vital signs, deep tendon reflexes; serum magnesium
calcium, and potassium levels; renal function
Obstetrics: Vital signs, oxygen saturation, deep tendon flexes, level of consciousness, foetal heart
rate; maternal uterine activity

Availability
Oral magnesium (elemental) 200 mg tabs available in pharmacy
Magnesium sulphate 49.3% (containing Mg 10 mmol per 5 mL) available in pharmacy and E-kit.
2+

These are dispensed on prescription-only basis.

References
st
1. Drug Information Handbook (21 edition), 2012-2013
2. Patient Information Leaflet (DBL Magnesium Sulfate Concentrated Injection).

For any clarification regarding this document, contact any pharmacist at Drug Information (Ext. 1885)

Prepared/ Reviewed by: Mr Ian Wee, Clinical Pharmacist, Dept of Pharmacy

13 Jan 2010 Dr Noelle Lim, Senior Consultant, Dept of Anaesthesia
Dr Siau Chuin, Consultant, Dept of Medicine

st
1 revision: Mr Ian Wee, Principal Clinical Pharmacist, Dept of Pharmacy
8 Jan 2014 Ms Elena Lee, Senior Clinical Pharmacist, Dept of Pharmacy