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# Calcium Acetate
## Overview
Calcium acetate is a phosphate binder used to reduce serum phosphate levels in patients with hyperphosphatemia, primarily those with chronic kidney disease. It works by binding to dietary phosphate in the gastrointestinal tract, forming insoluble calcium phosphate, which is then excreted in the feces.
## Primary Indications
* Treatment of hyperphosphatemia in patients with end-stage renal disease (ESRD).
## Adult Dosing
* **Initial dose:** 667 mg (13.3 mEq elemental calcium) administered orally with each meal.
* **Titration:** Dosage should be individualized based on serum phosphate levels. Increments of 667 mg per meal may be made as needed.
* **Maximum dose:** Generally not to exceed 13.3 grams (266 mEq elemental calcium) per day. However, total daily calcium intake (from supplements, diet, and antacids) should be monitored.
## Pediatric Dosing
* Dosing in pediatric patients is not well established and should be individualized under specialist guidance. Some sources suggest starting at 1-2 grams per day divided into 3-4 doses with meals, titrating based on serum phosphate levels.
## Dose Adjustments
* **Renal Impairment:** Dosage adjustment is necessary. Patients with ESRD are the primary indication, but caution is needed regarding cumulative calcium load and potential for hypercalcemia.
* **Hypercalcemia:** If hypercalcemia occurs, the dose should be reduced or interrupted.
## Contraindications
* Hypercalcemia.
* Conditions associated with hypercalcemia, such as hyperparathyroidism and certain malignancies.
* Hypersensitivity to calcium acetate.
## Adverse Effects
* **Common:** Hypercalcemia (most significant), constipation, nausea, vomiting, abdominal pain, diarrhea.
* **Serious:** Severe hypercalcemia can lead to cardiac arrhythmias, hyporeflexia, confusion, coma, and renal calcification.
## Key Drug Interactions
* **Tetracyclines and Quinolones:** Calcium acetate can decrease the absorption of these antibiotics. Administer them at least 2 hours before or 6 hours after calcium acetate.
* **Thyroid Hormones (Levothyroxine):** Calcium acetate can decrease the absorption of levothyroxine. Separate administration by at least 4 hours.
* **Bisphosphonates:** Concurrent use may reduce the absorption of bisphosphonates. Separate administration by at least 2 hours.
* **Certain Antacids:** Concurrent use may increase the risk of hypercalcemia.
* **Digoxin:** Hypercalcemia associated with calcium acetate may increase the risk of digoxin toxicity.
* **Thiazide Diuretics:** May increase the risk of hypercalcemia.
## Monitoring
* **Serum Phosphate:** Regularly monitor to assess efficacy and guide dose titration.
* **Serum Calcium:** Regularly monitor to detect and prevent hypercalcemia.
* **Alkaline Phosphatase:** Monitor in patients with renal osteodystrophy.
* **Renal Function:** Monitor as appropriate.
## Clinical Pearls
* Administer with meals to maximize phosphate binding.
* Monitor total calcium intake from all sources to avoid excessive levels.
* Hypercalcemia is a dose-limiting toxicity and requires prompt management.
* Ensure adequate hydration to help prevent kidney stone formation.
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**Disclaimer:** This information is intended for clinical use and is not a substitute for professional medical advice. Always consult the most current prescribing information and relevant clinical guidelines before making treatment decisions. Dosing and recommendations may vary based on individual patient factors and local protocols.
