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# Dicitral (Potassium Citrate/Citric Acid)
## Overview
Dicitral is a urinary alkalinizing agent. It functions by increasing the concentration of citrate in the urine, which inhibits the crystallization of calcium salts (calcium oxalate and calcium phosphate) and restores the normal alkaline environment.
## Primary Indications
* Management of renal tubular acidosis (RTA) with calcium calculi.
* Prevention of calcium oxalate nephrolithiasis.
* Prevention of uric acid lithiasis.
## Adult Dosing
Standard dosing typically ranges from 30 to 60 mEq of citrate daily, divided into three or four doses.
* **Typical Starting Dose:** 10–20 mEq administered after meals and at bedtime.
* **Titration:** Dosed based on urinary citrate levels (target >320 mg/day) and urinary pH (target 6.5–7.0). Do not exceed systemic alkalosis thresholds.
## Pediatric Dosing
**Note:** Use with extreme caution. Dosing is highly dependent on institutional protocol and degree of metabolic acidosis.
* **General Guideline:** 1–2 mEq/kg/day, divided into 3–4 doses. Monitor serum electrolytes and urinary pH closely to prevent hyperkalemia or over-alkalinization.
## Dose Adjustments
* **Renal Impairment:** Contraindicated in patients with severe renal impairment (GFR <30 mL/min) due to the high risk of hyperkalemia.
* **Hepatic Impairment:** No specific adjustment required; however, careful monitoring of electrolyte status is advised if metabolic capacity is compromised.
## Contraindications
* Hyperkalemia (or conditions predisposing to it).
* Severe renal impairment (CrCl <30 mL/min).
* Active urinary tract infection (urease-splitting organisms).
* Uncontrolled diabetes mellitus.
* Peptic ulcer disease or gastrointestinal obstruction.
## Adverse Effects
* **Gastrointestinal:** Nausea, vomiting, diarrhea, abdominal discomfort (mitigate by taking with food or diluting).
* **Metabolic:** Hyperkalemia (serious), metabolic alkalosis.
* **Other:** Mild laxative effect.
## Key Drug Interactions
* **Potassium-sparing diuretics (e.g., spironolactone, triamterene):** Markedly increases risk of life-threatening hyperkalemia.
* **ACE Inhibitors/ARBs:** Potentiates hyperkalemia.
* **Aluminum-containing antacids:** Citrate may significantly increase aluminum absorption; separate administration by at least 2 hours.
## Monitoring
* **Electrolytes:** Baseline and periodic serum potassium and bicarbonate levels.
* **Urinary:** 24-hour urine collection for citrate, calcium, uric acid, and pH (target pH 6.5–7.0).
* **Renal Function:** Monitor serum creatinine and BUN regularly.
## Clinical Pearls
* **Administration:** Always administer after meals or with a full glass of water to minimize GI irritation.
* **Patient Education:** High salt intake may counteract the efficacy of citrate; maintain adequate hydration.
* **Uncertainty:** Dosing is highly individualized; always titrate to urinary metabolic parameters rather than utilizing a fixed regimen.
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**Educational Disclaimer:** This information is for educational purposes only. Clinical guidelines and protocols vary by institution. Verify all dosages, contraindications, and drug interactions against the most current product labeling and your local clinical decision support systems/pharmacology database before prescribing or administering.
