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# Calcium Acetate
## Overview
Calcium acetate is a phosphate binder used to control hyperphosphatemia in patients with chronic kidney disease (CKD). It works by binding to dietary phosphate in the gastrointestinal tract, forming insoluble calcium phosphate, which is then excreted in the feces.
## Primary Indications
* Management of hyperphosphatemia in patients with end-stage renal disease (ESRD).
## Adult Dosing
* **Initial dose:** 2 tablets (667 mg calcium acetate per tablet, providing approximately 169 mg elemental calcium and 132 mg acetate per tablet) taken orally with meals.
* **Titration:** Doses should be individualized based on serum phosphate levels. Doses can be increased by 1-2 tablets per meal as needed.
* **Maximum dose:** Typically 12-16 tablets per day, divided among meals, but individual tolerance and serum calcium levels must be considered. The goal is to maintain serum phosphate below 6 mg/dL.
## Pediatric Dosing
* Dosing in pediatric patients is not well established and should be individualized under the guidance of a pediatric nephrologist. Some sources suggest starting doses based on age and weight, but these are not standardized.
## Dose Adjustments
* **Renal Impairment:** Dosing is primarily for CKD patients. Close monitoring of serum calcium and phosphate is essential.
* **Hypercalcemia:** If hypercalcemia occurs, the dose should be reduced or temporarily discontinued. Calcium-rich antacids should also be avoided.
## Contraindications
* Hypercalcemia.
* Hypersensitivity to calcium acetate.
* Concomitant use with intravenous (IV) calcium salts.
## Adverse Effects
* **Common:** Hypercalcemia (most significant concern), constipation, nausea, vomiting, abdominal pain.
* **Less Common:** Hypophosphatemia, acid rebound (with rapid administration or large doses), xerostomia.
## Key Drug Interactions
* **Tetracyclines and Fluoroquinolones:** Calcium acetate can decrease the absorption of these antibiotics. Administer antibiotics at least 2 hours before or 3 hours after calcium acetate.
* **Digoxin:** Hypercalcemia can potentiate digoxin toxicity.
* **Thyroid Hormones:** Calcium acetate may decrease absorption. Separate administration by at least 4 hours.
* **Bisphosphonates:** Concurrent use may decrease absorption of bisphosphonates. Separate administration by at least 2 hours.
* **Calcium Channel Blockers:** Hypercalcemia may affect the response to calcium channel blockers.
* **Vitamin D Analogs:** Increased risk of hypercalcemia.
## Monitoring
* **Serum Phosphate:** Monitor regularly to guide dosing and assess efficacy.
* **Serum Calcium:** Monitor regularly to prevent or manage hypercalcemia.
* **Alkaline Phosphatase:** May be monitored in patients with renal osteodystrophy.
* **Electrolytes:** Monitor other electrolytes as clinically indicated.
## Clinical Pearls
* Calcium acetate should be taken with meals to effectively bind dietary phosphate.
* Patients should be educated about the signs and symptoms of hypercalcemia (e.g., nausea, vomiting, constipation, confusion, fatigue, increased thirst and urination).
* The total daily intake of elemental calcium from all sources (diet, supplements, phosphate binders) should not exceed 2000 mg.
* For patients receiving hemodialysis, calcium acetate is typically given three times a day when they are on the dialyzer.
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*Disclaimer: This information is intended for clinical decision-making and is not a substitute for professional medical advice. Always consult the most current prescribing information and relevant clinical guidelines for complete details.*
