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# Calcium Acetate
## Overview
Calcium acetate is a phosphate binder used to control hyperphosphatemia in patients with chronic kidney disease (CKD) on dialysis. It works by binding to dietary phosphate in the gastrointestinal tract, preventing its absorption.
## Primary Indications
* Hyperphosphatemia in patients with end-stage renal disease (ESRD) receiving dialysis.
## Adult Dosing
The dose is highly individualized based on serum phosphate levels and dietary phosphate intake. Doses should be taken with meals.
* **Initial dose:** 667 mg (13.3 mEq calcium) three times daily with meals.
* **Titration:** Adjust dose based on serum phosphate levels. Target serum phosphate is typically < 5.5 mg/dL.
* **Maximum dose:** Generally considered to be 10-12 grams (200-240 mEq calcium) per day, but higher doses may be used cautiously under close monitoring.
## Pediatric Dosing
Dosing in pediatric patients is not well established and should be individualized by a specialist. The following is a guideline:
* **Children:** 1.0-1.7 grams (20-34 mEq calcium) per kilogram per day divided into multiple doses with meals.
* **Maximum dose:** Not established.
## Dose Adjustments
* **Renal Impairment:** Dose adjustment is not required for renal impairment, as the indication is for patients with ESRD on dialysis. However, patients with CKD not on dialysis should be monitored closely for hypercalcemia and vascular calcification.
* **Hepatic Impairment:** No specific dose adjustments are recommended.
## Contraindications
* Hypercalcemia.
* Hypersensitivity to calcium acetate or any component of the formulation.
* Conditions causing hypercalcemia (e.g., sarcoidosis, certain malignancies, vitamin D intoxication).
## Adverse Effects
* **Common:** Hypercalcemia (most significant), nausea, vomiting, constipation, diarrhea, anorexia.
* **Serious:** Vascular calcification, hypotension (especially with IV administration, though this formulation is oral), cardiac arrhythmias (associated with hypercalcemia).
## Key Drug Interactions
* **Tetracyclines and Quinolones:** Calcium acetate can decrease the absorption of these antibiotics. Separate administration by at least 2 hours.
* **Thyroid Hormones:** Calcium acetate can decrease the absorption of levothyroxine. Separate administration by at least 4 hours.
* **Biphosphonates:** Separate administration by at least 2 hours.
* **Digoxin:** Hypercalcemia can increase the risk of digoxin toxicity.
* **Calcium Channel Blockers:** Hypercalcemia can antagonize the effects of calcium channel blockers.
* **Thiazide Diuretics:** May increase serum calcium levels, increasing the risk of hypercalcemia.
* **Vitamin D Analogs:** Increase the absorption of calcium and the risk of hypercalcemia.
## Monitoring
* **Serum Calcium:** Monitor frequently, especially during dose initiation and titration. Goal is to maintain serum calcium within the normal range or slightly above, depending on institutional protocol.
* **Serum Phosphate:** Monitor regularly to assess efficacy.
* **Alkaline Phosphatase:** May be monitored to assess bone turnover.
* **Renal Function:** Monitor BUN and creatinine if baseline renal function is not known or significantly impaired.
## Clinical Pearls
* Calcium acetate should be taken with meals to effectively bind dietary phosphate.
* If patients are also taking medications that require administration on an empty stomach (e.g., certain antibiotics, thyroid hormone), ensure adequate separation to avoid absorption issues.
* Hypercalcemia is the most critical adverse effect; educate patients on symptoms (e.g., constipation, nausea, fatigue, confusion, frequent urination) and to report them promptly.
* The amount of elemental calcium per gram of calcium acetate is approximately 252 mg. Each 667 mg tablet contains approximately 168 mg of elemental calcium.
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*Disclaimer: This information is intended for healthcare professionals. It is essential to consult the most current prescribing information and relevant clinical guidelines for complete details and to verify dosages and recommendations before patient administration.*
