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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
* Treatment of hyperphosphatemia in patients with end-stage renal disease (ESRD) on hemodialysis or peritoneal dialysis.
## Adult Dosing
* **Initiation:** Typically 667 mg (elemental calcium 169 mg) orally with each meal.
* **Titration:** Dosage should be individualized based on serum phosphorus levels. Doses can be increased by 667 mg per meal increments as needed.
* **Target:** Aim to reduce serum phosphorus to below 6 mg/dL.
* **Maximum:** There is no strict maximum dose, but doses exceeding 4000 mg (elemental calcium ~1000 mg) per day are generally not recommended due to the risk of hypercalcemia and constipation. Monitor serum calcium closely.
## Pediatric Dosing
* **Pediatric patients (6 years and older):** Dosing is not well established. Dosing should be individualized based on serum phosphorus levels, with caution. A common starting point is 667 mg (elemental calcium 169 mg) orally with meals, similar to adults, but requires careful monitoring.
* **Children younger than 6 years:** Safety and efficacy have not been established.
## Dose Adjustments
* **Renal Impairment:** Not applicable in the intended ESRD population. However, in patients with CKD not on dialysis, caution and close monitoring of calcium and phosphate levels are required.
* **Hepatic Impairment:** No specific dose adjustments are typically needed.
## Contraindications
* Hypercalcemia.
* Hypersensitivity to calcium acetate.
* Certain conditions associated with hypercalcemia, such as metastatic bone disease or conditions causing ectopic calcification.
## Adverse Effects
* **Common:** Constipation, nausea, vomiting.
* **Serious:** Hypercalcemia (symptoms include anorexia, nausea, vomiting, constipation, abdominal pain, polyuria, polydipsia, muscle weakness, lethargy, confusion, arrhythmias, coma), adynamic bone disease (with long-term excessive calcium intake).
## 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 (levothyroxine):** Calcium acetate can decrease the absorption of levothyroxine. Administer levothyroxine at least 4 hours before or 4 hours after calcium acetate.
* **Digoxin:** Hypercalcemia associated with calcium acetate can potentiate digoxin toxicity.
* **Calcium channel blockers:** Hypercalcemia may reduce the efficacy of calcium channel blockers.
* **Vitamin D and its analogs:** These can increase calcium absorption and the risk of hypercalcemia.
## Monitoring
* **Serum Phosphorus:** Monitor regularly (frequency determined by clinical status and dose) to guide dosing.
* **Serum Calcium:** Monitor regularly (frequency determined by clinical status and dose, at least monthly) to detect and manage hypercalcemia.
* **Albumin-corrected calcium:** If serum albumin is abnormal.
* **Electrolytes:** Monitor periodically.
* **Signs and symptoms of hypercalcemia.**
## Clinical Pearls
* Administer calcium acetate with meals to maximize phosphate binding.
* For patients unable to swallow capsules, the contents can be emptied and mixed with a small amount of food or liquid.
* Ensure adequate hydration to help manage constipation.
* If hypercalcemia develops, reduce the dose of calcium acetate or discontinue.
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*This information is intended for healthcare professionals and does not substitute for a comprehensive review of the full prescribing information. Always verify current prescribing information and consult with a qualified healthcare provider before making any treatment decisions.*
