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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.
## Primary Indications
* Treatment of hyperphosphatemia in patients with end-stage renal disease (ESRD).
## Adult Dosing
* **Typical Starting Dose:** 667 mg calcium acetate (equivalent to 13.3 mEq elemental calcium) orally with meals.
* **Titration:** Dosage should be individualized based on serum phosphate levels. Doses are typically increased in increments of 667 mg.
* **Maximum Dose:** While not strictly defined, doses up to 4000 mg (2000 mg of elemental calcium) per day have been used. However, doses should be limited to the lowest effective dose to avoid hypercalcemia.
## Pediatric Dosing
* Dosing in pediatric patients is not well established and should be individualized under specialist care. Some sources suggest starting doses based on age and weight, but data is limited.
## Dose Adjustments
* **Hypercalcemia:** If hypercalcemia occurs, reduce the dose or temporarily discontinue. Monitor calcium and phosphate levels closely.
* **Concomitant Medications:** Adjust administration time for certain medications (see Drug Interactions).
## Contraindications
* Hypercalcemia.
* Known hypersensitivity to calcium acetate.
* Conditions leading to hypercalcemia (e.g., certain malignancies, hyperparathyroidism).
## Adverse Effects
* **Common:** Hypercalcemia (manifested as constipation, nausea, vomiting, abdominal pain, dry mouth, thirst, polyuria, weakness, fatigue, headache, dizziness), hypophosphatemia.
* **Less Common:** Bradycardia, arrhythmias, altered mental status.
## Key Drug Interactions
* **Tetracyclines and Fluoroquinolones:** Calcium acetate can decrease absorption. Administer at least 2 hours before or 6 hours after these antibiotics.
* **Thyroid Hormones:** Calcium acetate may decrease absorption. Administer at least 4 hours apart.
* **Bisphosphonates:** May decrease absorption. Administer at least 2 hours before calcium acetate.
* **Cardiac Glycosides (e.g., Digoxin):** Hypercalcemia can potentiate cardiac toxicity. Use with caution.
* **Thiazide Diuretics:** May increase serum calcium levels. Monitor calcium levels.
## Monitoring
* **Serum Phosphate:** Monitor regularly, typically within weeks of starting therapy and after dose adjustments. The goal is generally to maintain serum phosphate below 5.5 mg/dL.
* **Serum Calcium:** Monitor regularly, especially when initiating or adjusting doses, or if symptoms of hypercalcemia develop.
* **Alkaline Phosphatase:** Monitor in patients with CKD.
* **Intact Parathyroid Hormone (iPTH):** Monitor as part of the management of secondary hyperparathyroidism.
## Clinical Pearls
* Administer with meals to maximize phosphate binding.
* Dose should be individualized to achieve target phosphate levels while avoiding hypercalcemia.
* Hypercalcemia is the most common dose-limiting toxicity. Patients with low calcium-phosphorus product are less likely to develop hypercalcemia.
* Consider alternative phosphate binders if hypercalcemia is difficult to manage.
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**Disclaimer:** This information is intended for clinical use and is not a substitute for professional medical advice. Always consult the most current prescribing information and guidelines for definitive drug management.
