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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 binds to dietary phosphate in the gastrointestinal tract, preventing its absorption.
## Primary Indications
* Management of hyperphosphatemia in patients with end-stage renal disease (ESRD).
## Adult Dosing
* **Typical starting dose:** 2 tablets (667 mg elemental calcium per tablet) orally with each meal.
* **Titration:** Dose should be individualized based on serum phosphate levels.
* **Maximum dose:** Generally not to exceed 12 tablets (8004 mg elemental calcium) per day. Doses higher than this may increase the risk of hypercalcemia and should be used with extreme caution and close monitoring.
## Pediatric Dosing
* Dosing in pediatric patients is not well-established and should be determined by a pediatric nephrologist. Close monitoring for efficacy and safety is crucial.
## Dose Adjustments
* No specific dose adjustments are typically required for renal or hepatic impairment, as the primary goal is to manage phosphate levels in patients with CKD. However, caution is warranted in patients with any degree of renal insufficiency due to the risk of hypercalcemia.
## Contraindications
* Hypercalcemia.
* Conditions causing hypercalcemia, such as multiple myeloma, sarcoidosis, or certain metastatic bone tumors.
* Patients with a known hypersensitivity to calcium acetate.
## Adverse Effects
* **Common:** Hypercalcemia (symptoms include nausea, vomiting, constipation, abdominal pain, confusion, lethargy, polyuria, polydipsia), hypophosphatemia.
* **Less Common:** Gastrointestinal upset, dry mouth.
## Key Drug Interactions
* **Tetracyclines and Fluoroquinolones:** Calcium acetate can decrease the absorption of these antibiotics. Administer at least 2 hours before or 6 hours after calcium acetate.
* **Thyroid Hormones:** Calcium acetate can decrease absorption of levothyroxine. Administer levothyroxine at least 4 hours apart from calcium acetate.
* **Digitalis Glycosides:** Hypercalcemia can increase the risk of digitalis toxicity.
* **Biphosphonates:** Concurrent use may lead to decreased absorption of biphosphonates. Separate administration by at least 2 hours.
* **Certain Antacids:** Concurrent use may increase the risk of hypercalcemia.
## Monitoring
* **Serum Calcium:** Monitor regularly, especially when initiating therapy or increasing the dose. Target is generally within the normal range or slightly above, depending on institutional guidelines and patient-specific goals.
* **Serum Phosphate:** Monitor regularly to assess efficacy.
* **Serum Bicarbonate:** Monitor for potential metabolic alkalosis.
* **Alkaline Phosphatase:** Monitor for changes.
## Clinical Pearls
* Administer calcium acetate with meals to effectively bind dietary phosphate.
* Be vigilant for signs and symptoms of hypercalcemia, as this is a common and dose-limiting toxicity.
* Individualize dosing to achieve target phosphate levels while minimizing the risk of hypercalcemia. Many protocols aim for serum phosphate levels < 5.5 mg/dL.
* Consider the total elemental calcium content when calculating doses and assessing risk of hypercalcemia, especially if the patient is receiving other calcium-containing supplements or medications. Each 667 mg tablet contains approximately 169 mg of elemental calcium.
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**Disclaimer:** This information is intended for healthcare professionals. Always consult the most current prescribing information and institutional protocols before making clinical decisions.
