AMMONIUM CHLORIDE 0.9% IN NORMAL SALINE
Clinical safety rating: caution
Comprehensive clinical and safety monograph for AMMONIUM CHLORIDE 0.9% IN NORMAL SALINE (AMMONIUM CHLORIDE 0.9% IN NORMAL SALINE).
Ammonium chloride provides chloride ions to correct hypochloremic metabolic alkalosis and acts as a systemic acidifying agent. It is metabolized to urea and hydrochloric acid in the liver, thereby increasing hydrogen ion concentration in plasma and lowering pH.
| Metabolism | Hepatic: ammonium chloride is converted to urea (via the urea cycle) and hydrochloric acid; enzymes include carbamoyl phosphate synthetase I, ornithine transcarbamylase, and arginase. |
| Excretion | Renal: >95% as ammonium and chloride ions; minimal biliary/fecal elimination. |
| Half-life | Variable; approximately 2-4 hours depending on renal function and acid-base status; prolonged in renal impairment. |
| Protein binding | <10% bound to plasma proteins. |
| Volume of Distribution | 0.3-0.5 L/kg; distributes primarily in extracellular fluid. |
| Bioavailability | Oral: ~100% (well absorbed); IV: 100% (bioequivalent). |
| Onset of Action | IV: Rapid, within minutes for metabolic acidosis correction; oral: 1-2 hours. |
| Duration of Action | IV: 4-6 hours for acidifying effect; oral: 6-8 hours; duration depends on continuous acid load. |
Adults: 0.9% ammonium chloride in normal saline, intravenous infusion at a rate of 0.5-1 mL/kg/hour, typically 500-1000 mL over 4-8 hours, adjusted based on serum chloride and pH. Maximum infusion rate: 1 mL/kg/hour.
| Dosage form | INJECTABLE |
| Renal impairment | GFR <30 mL/min: Avoid use due to risk of hyperchloremic metabolic acidosis and ammonium accumulation. GFR 30-50 mL/min: Initiate at 50% of standard rate, monitor serum ammonium and electrolytes. No adjustment for GFR >50 mL/min. |
| Liver impairment | Child-Pugh Class B or C: Contraindicated due to impaired urea synthesis and risk of hepatic encephalopathy. Child-Pugh Class A: Caution; monitor serum ammonia and reduce infusion rate by 50%. |
| Pediatric use | Children: Initial dose 0.5-1 mEq/kg of ammonium ion (1 mEq/kg = 0.1 mL/kg of 0.9% solution) as a slow IV infusion over 4-6 hours. Maximum rate: 0.5 mL/kg/hour. Titrate based on serum pH and chloride. |
| Geriatric use | Use with caution due to age-related decline in renal function; start at lower end of dosing range (0.5 mL/kg/hour) and monitor renal function and electrolytes closely. Adjust dose per renal function. |
| 1st trimester | Consult provider |
| 2nd trimester | Consult provider |
| 3rd trimester | Consult provider |
Clinical note
Comprehensive clinical and safety monograph for AMMONIUM CHLORIDE 0.9% IN NORMAL SALINE (AMMONIUM CHLORIDE 0.9% IN NORMAL SALINE).
| Breastfeeding | Ammonium chloride is excreted into breast milk, but concentrations are low and not expected to harm the nursing infant. The M/P ratio is unknown. It is considered compatible with breastfeeding if used at recommended doses. Monitor infant for signs of acidosis if high doses are used. |
| Teratogenic Risk | Ammonium chloride is a urine acidifier with limited data in pregnancy. It is generally considered low risk for teratogenicity based on animal studies and lack of human adverse reports. However, maternal metabolic acidosis from overdose could theoretically harm the fetus. First trimester: no known teratogenic effect. Second and third trimesters: minimal risk unless maternal acidosis occurs. Use only if clearly needed. |
■ FDA Black Box Warning
None
| Serious Effects |
Severe hepatic insufficiency (cirrhosis, hepatitis), severe renal impairment (anuria, oliguria), primary respiratory acidosis, hypernatremia, and known hypersensitivity to any component.
| Precautions | Use with caution in patients with hepatic impairment (risk of hyperammonemia and hepatic encephalopathy), renal impairment (risk of metabolic acidosis), or respiratory acidosis. Monitor serum ammonia, chloride, bicarbonate, and pH levels. Rapid infusion may cause local irritation, phlebitis, and metabolic acidosis. |
| Food/Dietary | Avoid high-sodium foods or salt substitutes that contain potassium, as this may affect electrolyte balance. No specific food restrictions are required, but maintain a balanced diet as advised by your healthcare provider. |
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| Fetal Monitoring | Monitor maternal serum electrolytes, acid-base status (pH, bicarbonate), and renal function. In pregnancy, assess for signs of metabolic acidosis. Fetal monitoring is not routinely required but consider if maternal acidosis develops. |
| Fertility Effects | No known adverse effects on fertility in animal studies. Human data are lacking. No expected impact on reproductive function at therapeutic doses. |
| Clinical Pearls | 0.9% ammonium chloride in normal saline is an acidifying agent used to correct metabolic alkalosis. Monitor serum electrolytes, pH, and bicarbonate closely during infusion. Avoid in patients with severe hepatic or renal impairment. Administer via central line due to hypertonicity (approximately 900 mOsm/L). Can cause hyperammonemia in hepatic failure; use with caution in hypokalemia as it may exacerbate potassium loss. |
| Patient Advice | This medication is given intravenously to treat alkalosis (high blood pH). · You may experience pain or burning at the IV site; report any discomfort. · Tell your doctor if you have liver or kidney disease. · Do not take potassium supplements or salt substitutes without consulting your doctor. · Inform your healthcare provider of all medications you are taking. |