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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 dietary phosphate in the gastrointestinal tract, preventing its absorption.
## Primary Indications
* Management of **hyperphosphatemia** in patients with **end-stage renal disease (ESRD)** on hemodialysis or peritoneal dialysis.
## Adult Dosing
* **Dose:** Typically initiated at **667 mg to 1332 mg (1 to 2 grams of elemental calcium) orally per meal**.
* **Titration:** Dosage should be titrated based on serum phosphate levels. Target serum phosphate is typically **< 5.5 mg/dL**.
* **Maximum Dose:** No established maximum dose, but aim for the lowest effective dose to control phosphate and minimize hypercalcemia. Some sources suggest a maximum of 10-12 grams of elemental calcium per day, but this is highly individualized.
## Pediatric Dosing
* Dosing in pediatric patients with CKD is less well-established and should be guided by a nephrologist.
* A starting dose of **10-20 mg/kg/day of elemental calcium divided with meals** has been suggested, but requires careful monitoring.
## Dose Adjustments
* **Renal Impairment:** Not applicable as it's used in patients with ESRD.
* **Hepatic Impairment:** No specific adjustment needed.
* **Hypercalcemia:** If hypercalcemia occurs, the dose of calcium acetate should be reduced or discontinued.
## Contraindications
* **Hypercalcemia:** Patients with elevated serum calcium levels.
* **Hypersensitivity** to calcium acetate or any component of the formulation.
* **Renal Calculi** (caution).
## Adverse Effects
* **Hypercalcemia:** The most common and significant adverse effect. Symptoms include constipation, nausea, vomiting, abdominal pain, dry mouth, increased urination, thirst, anorexia, confusion, lethargy, and cardiac arrhythmias.
* **Gastrointestinal:** Constipation, nausea, diarrhea, dyspepsia.
* **Other:** Headache, fatigue, itching.
## Key Drug Interactions
* **Tetracyclines and Fluoroquinolones:** Calcium acetate can decrease the absorption of these antibiotics. Separate administration by at least 2 hours (before or after).
* **Thyroid Hormones (Levothyroxine):** Calcium can decrease absorption. Separate administration by at least 4 hours.
* **Bisphosphonates:** Concurrent use may decrease the absorption of bisphosphonates. Separate administration.
* **Digitalis Glycosides:** Hypercalcemia induced by calcium acetate can increase the risk of digitalis toxicity. Monitor closely.
* **Antacids:** Concurrent use of other calcium-containing antacids may increase the risk of hypercalcemia.
* **Vitamin D Analogs:** Increased risk of hypercalcemia.
## Monitoring
* **Serum Phosphate:** Regularly monitor as a guide for dose titration.
* **Serum Calcium:** Crucial to monitor for hypercalcemia. Monitor at least twice weekly initially, then weekly, and then monthly once stable.
* **Albumin:** To correct calcium levels if hypoalbuminemia is present (ionized calcium is the true indicator).
* **Electrolytes and Renal Function:** Periodic monitoring.
## Clinical Pearls
* Administer **with meals** to effectively bind dietary phosphate.
* Use the **chewable tablet formulation** if available for easier administration.
* Be aware that calcium acetate contributes to the total daily calcium load; consider this when managing patients with a history of calcium-based kidney stones.
* Patients should be advised to report symptoms of hypercalcemia immediately.
* The goal is to achieve the lowest effective dose to maintain target phosphate levels while avoiding hypercalcemia.
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*This information is for educational purposes only and does not constitute medical advice. Always consult with a qualified healthcare provider to ensure the information is applicable to your specific situation and to confirm the most current prescribing information.*
