Generic Name

Excreted solely by the kidneys at a rate proportional to the

serum concentration and glomerular filtration.

Magnesium Sulfate

Onset

Trade Names
Epsom Salt
- Granules, oral
Magnesium Sulfate
- Injection, solution 4% (elemental magnesium 0.325 mEq/mL)
- Injection, solution, concentrate 8% (elemental magnesium
0.65 mEq/mL)
- Injection, solution, concentrate 50% (elemental magnesium 4
mEq/mL)

Immediate (IV, when used as an anticonvulsant); 1 h (IM).

Duration
30 min (IV, when used as an anticonvulsant); 3 to 4 h (IM).

Special Populations
Renal Function Impairment

Magnesium Sulfate in Dextrose 5%

- Injection, solution 1% (elemental magnesium 0.081 mEq/mL)
- Injection, solution 2% (elemental magnesium 0.162 mEq/mL)

No data available.

Pharmacology

No data available.

Magnesium is an important activator of many enzyme systems,

and deficits are accompanied by a variety of functional
disturbances. Magnesium has CNS depressant effects; it
prevents/controls seizures by blocking neuromuscular
transmission and decreasing the amount of acetylcholine
liberated at end plate by motor nerve impulse. Orally, it
attracts/retains water in intestinal lumen, thereby increasing
intraluminal pressure and inducing the urge to defecate.

Pharmacokinetics
Absorption
Immediately absorbed (IV).

Distribution
Approximately 1% to 2% of total body magnesium is in the
extracellular fluid space; 30% bound to albumin.

Metabolism
Magnesium is not metabolized.

Elimination

Hepatic Function Impairment

Indications and Usage

Parenteral
Seizure prevention and control in severe preeclampsia or
eclampsia; replacement therapy in magnesium deficiency,
especially in acute hypomagnesemia accompanied by signs of
tetany similar to those observed in hypocalcemia; corrects or
prevents hypomagnesemia by addition to TPN admixture;
control hypertension, encephalopathy, and convulsions in
children with acute nephritis.
Oral
Laxative.

Unlabeled Uses
Treatment of acute exacerbation of severe asthma; treatment of
torsades de pointes; paroxysmal atrial tachycardia; cerebral
edema; barium poisoning.

Contraindications
Toxemia of pregnancy during 2 h preceding delivery.

Dosage and Administration

Hyperalimentation
Adults
TPN 5 to 8 mEq of magnesium per 1 L of TPN solution. Typical
daily intakes range from 10 to 24 mEq/day.
Children
TPN 0.25 to 0.6 mEq/kg/day.
Hypomagnesemia
Adults Mild hypomagnesemia
IM 1 g (2 mL of undiluted 50% solution) injected every 6 h for 4
doses.
Severe hypomagnesemia
IV / IM As much as 246 mg/kg (0.5 mL/kg of the undiluted 50%
solution) may be given within a period of 4 h if necessary.
Alternatively, 5 g (10 mL) can be added to 1 L of dextrose 5%
injection or sodium chloride 0.9% injection for slow IV infusion
over a 3-h period. According to American Heart Association
(AHA) guidelines, the recommended dosage is 1 to 2 g IV over
5 to 60 min. If seizures are present, give 2 g IV over 10 min.
Use caution so as not to exceed the renal excretion capacity.
Laxative
Usually a one-time dose.

should continue until paroxysms cease. According to American

College of Obstetricians and Gynecologists guidelines, the
initial dosage is 4 to 6 g (diluted in 100 mL) given IV over 15 to
20 min, followed by a maintenance dosage of 2 g/h continuous
IV infusion.
Off-Label Uses
Asthma (life-threatening) Adults
IV 1.2 to 2 g over 20 min according to AHA/American College
of Cardiology (ACC) guidelines.
Children
IV 25 to 75 mg/kg (max dose, 2 g) over 20 min every 4 to 6
hours for 3 or 4 doses; repeat as needed.
Barium Poisoning Adults
IV 1 to 2 g.
Cerebral Edema Adults
IV 2.5 g (25 mL of a 10% solution).
Hypomagnesemia Children
IV / intraosseous 25 to 50 mg/kg (max dose, 2 g) over 10 to 20
min every 4 to 6 h for 3 or 4 doses; repeat as needed.
Paroxysmal Atrial Tachycardia Adults

PO 10 to 15 g.

IV 3 to 4 g (30 to 40 mL of a 10% solution) over 30 sec with

extreme caution. Use only if simpler measures have failed and
there is no evidence of myocardial damage.

Children

Torsades de Pointes Adults

PO 5 to 10 g.

IM 20 to 40 mg/kg (0.1 to 0.2 mL/kg of a 20% solution) as

needed to control seizures.

IV The following recommendations are according to AHA/ACC

guidelines. If torsades de pointes is associated with cardiac
arrest, 1 to 2 g (diluted in 10 mL of dextrose 5% injection)
administered IV/intraosseous over 5 to 20 min. If torsades de
pointes is intermittent and not associated with cardiac arrest,
dilute 1 to 2 g in 50 to 100 mL of dextrose 5% injection and
administer over 5 to 60 min.

Seizures in Eclampsia/Preeclampsia

Children

Adults

Nephritic Seizures
Children

IM / IV 10 to 14 g (as a combination of 4 to 5 g of undiluted

50% solution in each buttock and 4 to 5 g IV in 250 mL of
dextrose 5% injection or sodium chloride 0.9% injection, or 4 g
of magnesium/dextrose 5% injection premixed solution).
Alternatively, the initial IV dose of 4 g may be given by diluting
the 50% solution to a 10% or 20% solution and the diluted fluid
(40 mL of a 10% solution or 20 mL of a 20% solution) may be
injected over 3 to 4 minutes. After the initial dose, 1 to 2 g/h by
constant IV infusion or IM doses of 4 to 5 g of undiluted 50%
solution every 4 h injected into alternate buttocks as needed
(max, 30 to 40 g per 24 h and less in anuric patients). Therapy

IV According to AHA/ACC guidelines, the dosage is 25 to 50

mg/kg (max dose, 2 g) IV/intraosseous over several min.
Renal impairment
The dose should be lower and frequent serum magnesium
levels must be obtained. Consider reducing the dose by 50%
(max adults, 20 g per 48 h).

General Advice

Injection

For IM or IV administration only. Not for intradermal,

subcutaneous, or intra-arterial administration. IM
administration is painful; avoid if possible.

IV bolus may cause flushing, sweating, and warm

sensation; avoid if possible.

Rate of IV injection should generally not exceed 150

mg/min (1.5 mL of a 10% concentration or 7.5 mL of a 2%
concentration or its equivalent), except in severe
eclampsia with seizures.

50% solution may be administered undiluted to adults

if given by deep IM injection. Rotate injection sites to
reduce tissue irritation.

50% solution must be diluted with sodium chloride

0.9% injection or dextrose 5% injection to a concentration
of 20% or less before IV administration or IM
administration in infants and children.

When administering via IV route, use infusion pump.

Deliver in separate line and do not mix with other IV drugs
unless compatibility has been established.

Have an IV calcium preparation at hand as an

antidote.

Prior to repeat doses, test for knee-jerk reflexes. If

they are absent, no additional magnesium should be given
until reflexes return.

Incompatibilities: alcohol (in high concentrations),

alkali carbonates and bicarbonates, alkali hydroxides,
arsenates, barium, calcium, clindamycin, heavy metals,
hydrocortisone sodium succinate, phosphates, polymyxin
B, procaine, salicylates, streptomycin, strontium, tartrates,
tetracycline, tobramycin.

Chloroquine, eltrombopag:
Oral magnesium sulfate
may decrease the absorption and clinical effect of
chloroquine or eltrombopag. Separate the administration
times of chloroquine and oral magnesium sulfate by 2 to 4
h. Higher doses of chloroquine may be needed. Separate
the administration times of eltrombopag and oral
magnesium sulfate by at least 4 h.
Neuromuscular blocking agents: Potentiation of
neuromuscular blockade; use with caution. Monitor for
respiratory depression. Adjust the neuromuscular blocking
agent dose as needed. Be prepared to provide life
support.

Nifedipine:
The risk of neuromuscular blockade and
hypotension may be increased. Closely monitor the clinical
response. Be prepared to provide supportive treatment or
to discontinue one or both drugs if needed.
Nitrofurantoin: Decreased absorption of nitrofurantoin (oral
magnesium). Separate the administration times by as
much as possible.
Penicillamine: Reduced penicillamine effects (oral
magnesium). No special precautions are needed.

Tetracyclines: Decreased absorption of tetracyclines (oral

magnesium). Separate the administration times by 3 to 4
h.

Adverse Reactions
Cardiovascular:

Cardiac arrest; cardiac depression;

circulatory collapse; hypotension.

CNS:

CNS depression; depressed reflexes; flaccid

paralysis.

Metabolic:

Hypermagnesemia; hypocalcemia with signs

Respiratory:

Respiratory depression; respiratory

of tetany.

Storage/Stability
Store at 68 to 77F. Protect from freezing. Discard
any unused solution. Unused portions of the undiluted 50%
solution in the container should be discarded within 24 h of
initial use.

paralysis.

Miscellaneous:

Flushing; hypothermia; sweating.

Precautions

Drug Interactions
Alcohol, aminoglycosides, amphotericin B, cisplatin,
cyclosporine, digitalis, diuretics

:Drug-induced renal losses of magnesium can occur.

Use with caution and closely monitor magnesium
concentrations.

Monitor:

Monitor serum magnesium levels and the

patient's clinical status to guide need for continued dosage.
Normal serum concentration is 1.5 to 2.5 or 3 mEq/mL.
Effective anticonvulsant serum levels range from 2.5 or 3 to 7.5
mEq/L (6 mg per 100 mL). Monitor levels hourly for patients
with severe hypomagnesemia until they reach 1.5 mEq/mL,

then every 6 to 12 h for the next 24 h. Once stable, obtain the

serum concentration daily. Carefully observe respiration and
BP during and after administration of IV magnesium. Urine
output should be maintained at 100 mL every 4 h. Clinical
indications of a safe dosage regimen include the presence of
the patellar reflex (knee-jerk) and absence of respiratory
depression (approximately 16 or more breaths per minute).
When repeated doses of the drug are given parenterally, kneejerk reflexes should be tested before each dose; if they are
absent, no additional magnesium should be given until they
return. The strength of the deep tendon reflexes begins to
diminish when magnesium levels exceed 4 mEq/L. Reflexes
may be absent at magnesium 10 mEq/L, where respiratory
paralysis is a potential hazard.

Symptoms
Decreased deep tendon reflexes, disappearance of patellar
reflex, ECG changes (ie, prolonged PR interval, prolonged
QRS complex, prolonged QT interval), heart block,
hypotension, respiratory paralysis.

Patient Information

Advise patient that medication will be prepared and

administered by a health care provider in a hospital
setting.

Instruct patient to notify health care provider if

drowsiness, muscle weakness, sweating, flushing, or
dizziness occurs.

Pregnancy:

Advise patient to mix granules in at least a half glass

of water before swallowing and to follow with a full glass of
water. Advise patient to mix with ice chips or flavor with
lemon or orange juice to make more palatable.

Educate patient regarding other measures that may

help prevent constipation (eg, adequate fluid intake,
dietary fiber, regular exercise).

Caution patient that drug is for short-term laxative use

only and that prolonged use can lead to dehydration and
electrolyte imbalance.

Advise patient to discontinue use and notify health

care provider of the following: unrelieved constipation,
rectal bleeding, symptoms of electrolyte imbalance (eg,
muscle cramps or pain, weakness, dizziness).

Category A / Category C , depending on

Excreted. The American Academy of

Pediatrics classifies magnesium as compatible with

breast-feeding.

Elderly:

May require reduced dosage because of

renal impairment.

Renal Function:

Use with caution; renal impairment

may lead to magnesium intoxication.

Aluminum toxicity:

Some of these products may

contain aluminum that may be toxic. Patients with impaired

kidney function, including premature neonates, who
receive parenteral levels of aluminum at more than 4 to 5
mcg/kg/day accumulate aluminum at levels associated
with CNS and bone toxicity. Tissue loading may occur at
even lower rates of administration.

Eclampsia:

Use IV form only for immediate control of life-

threatening convulsions.

Flushing/Sweating:
and sweating occurs.

Overdosage

Oral

manufacturer.

Lactation:

Injection

Administer with caution if flushing

Nursing Management
1. Hypomagnesemia/Anticonvulsant: Monitor pulse, blood
pressure, respirations, and ECG frequently throughout
administration of parenteral magnesium sulfate.
Respirations should be at least 16/min before each dose.
2. Monitor neurologic status before and throughout therapy.
Institute seizure precautions. Patellar reflex (knee jerk) should
be tested before each parenteral dose of magnesium sulfate. If
response is absent, no additional doses should be
administered until positive response is obtained.
3. Monitor intake and output ratios. Urine out put should be
maintained at a level of at least 100 ml/4 hr.

4. Explain purpose of medication to patient and family.