Protocol for Hypomagnesemia
Identification and Assessment
1. History and Physical Examination:
o Symptoms: Muscle cramps, tremors, weakness, seizures, arrhythmias,
confusion.
o Risk Factors: Chronic alcoholism, malnutrition, gastrointestinal losses (e.g., PPI,
diarrhea, vomiting), renal losses (e.g., diuretics, renal tubular disorders)
o Physical Examination: Neurological examination, cardiovascular examination.
2. Initial Laboratory Tests:
o Serum Magnesium: Confirm hypomagnesemia (normal range: 1.7-2.2 mg/dL).
o Serum Electrolytes: Calcium, potassium, and phosphate levels.
o Renal Function Tests: Serum creatinine, blood urea nitrogen (BUN).
o 24-Hour Urine Magnesium: To differentiate between renal and non-renal
losses.
3. ECG:
o Indications: Assess for arrhythmias (e.g., prolonged QT interval, torsades de
pointes).
Immediate Treatment
1. Mild Hypomagnesemia (1.0-1.6 mg/dL):
o Oral Magnesium Supplementation:
Magnesium Oxide: 400-800 mg orally daily in divided doses.
Magnesium Gluconate: Alternative oral preparation.
o Dietary Modification: Increase intake of magnesium-rich foods (e.g., nuts, green
leafy vegetables, whole grains).
2. Severe Hypomagnesemia (< 1.0 mg/dL) or Symptomatic:
o IV Magnesium Replacement:
Magnesium Sulfate: 1-2 grams IV over 30-60 minutes, followed by a
continuous infusion of 1-2 grams/hour until serum magnesium levels
normalize.
o Monitoring: Continuous cardiac monitoring for arrhythmias.
o Use caution in repleting magnesium in patients with abnormal kidney function
( creatinine clearance less than 30 mL/min/1.73 m2).
o In patients with concurrent hypocalcemia, replace calcium before initiating
magnesium replacement to avoid increased urinary excretion of calcium caused
by sulfate from magnesium sulfate.
o Potassium-sparing diuretics (amiloride or triamterene) should be considered in
patients with diuretic-induced hypomagnesemia (when diuretic therapy cannot
be discontinued) or chronic renal magnesium wasting.
3. Address Underlying Causes:
o Discontinue Offending Medications: If possible (e.g., diuretics).
o Treat GI Causes: Manage diarrhea, vomiting, malabsorption.
Monitoring and Follow-Up
1. Serum Magnesium Levels: Recheck every 6-12 hours initially, then daily until stable.
2. Serum Electrolytes: Monitor potassium and calcium levels, as hypomagnesemia can be
associated with other electrolyte imbalances.
3. ECG Monitoring: Continue until magnesium levels are normalized and arrhythmias are
resolved.
Long-term Management
1. Chronic Hypomagnesemia: Consider maintenance oral supplementation for patients
with recurrent hypomagnesemia.
2. Patient Education: Importance of adherence to supplementation and dietary
recommendations.
References
Cernaro, V., Lacquaniti, A., Lorenzano, G., Conte, G., & Buemi, M. (2019). "Magnesium in
Heart Failure: An Underestimated Mineral." Cardiorenal Medicine.
Guerin, C., Cousin, C., Mignot, L., & Manzon, C. (2016). "Acute Hypomagnesemia and
Hypocalcemia, and Their Management in Critically Ill Patients." Nutrients.
Cheungpasitporn, W., Thongprayoon, C., Mao, M.A., Thamcharoen, N., Erickson, S.B., &
Srivali, N. (2015). "Hypomagnesemia Linked to Hospital Mortality." Hospital Practice.
REF: CLINICAL HANDBOOK OF NEPHROLOGY 2024, ROBERT STEPHEN BROWN, MD
