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# Calcium Acetate
## Overview
Calcium acetate is a phosphate binder used to reduce serum phosphorus levels in patients with chronic kidney disease (CKD) on dialysis. It binds to dietary phosphate in the gastrointestinal tract, preventing its absorption.
## Primary Indications
* Hyperphosphatemia in patients with end-stage renal disease (ESRD) on hemodialysis or peritoneal dialysis.
## Adult Dosing
* **Initial Dose:** 667 mg (13.3 mEq calcium) orally with each meal.
* **Titration:** Dosage should be individualized based on serum phosphorus levels. Increase the dose gradually if hyperphosphatemia persists.
* **Maximum Dose:** Generally, 4000 mg (80 mEq calcium) per day, divided among meals. However, dose escalation may be guided by ongoing phosphorus levels and calcium goals.
## Pediatric Dosing
* Dosing in pediatric patients is not well-established and should be individualized under specialist guidance. Some sources suggest an initial dose of 10-12 mEq of elemental calcium per day divided with meals, with subsequent adjustments based on serum phosphorus and calcium levels.
## Dose Adjustments
* **Renal Impairment:** Not applicable in the typical indication of ESRD on dialysis. For patients with less severe renal impairment, caution and monitoring are advised.
* **Hepatic Impairment:** No specific dose adjustments are typically required.
## Contraindications
* Hypercalcemia.
* Hypersensitivity to calcium acetate.
* Concomitant use with medications that can increase calcium levels (e.g., calcium salts, vitamin D analogs).
## Adverse Effects
* **Common:** Hypercalcemia (most serious), hypophosphatemia, nausea, vomiting, constipation, diarrhea, abdominal pain, dry mouth.
* **Rare:** Calcification of soft tissues, kidney stones.
## Key Drug Interactions
* **Tetracyclines and Fluoroquinolones:** Calcium acetate can decrease the absorption of these antibiotics. Administer these agents at least 2 hours before or 3 hours after calcium acetate.
* **Thyroid Hormones:** Calcium acetate can reduce the absorption of levothyroxine. Separate administration by at least 4 hours.
* **Biphosphonates:** Avoid concurrent administration; separate by at least 3 hours.
* **Digitalis Glycosides:** Hypercalcemia may increase the risk of digitalis toxicity.
* **Vitamin D and its analogs:** Increased risk of hypercalcemia.
## Monitoring
* **Serum Phosphorus:** Monitor regularly (e.g., weekly initially, then monthly) to assess efficacy and guide dosing.
* **Serum Calcium:** Monitor regularly to prevent and detect hypercalcemia. Target serum calcium levels should be individualized but generally aimed at the upper end of the normal range.
* **Alkaline Phosphatase:** May be monitored to assess response in patients with renal osteodystrophy.
* **Signs and symptoms of hypercalcemia:** Monitor for nausea, vomiting, constipation, polyuria, polydipsia, weakness, confusion, and cardiac arrhythmias.
## Clinical Pearls
* Administer calcium acetate with meals to maximize dietary phosphate binding.
* Individualize dosing carefully to achieve target phosphorus levels while avoiding hypercalcemia.
* Ensure adequate dietary intake of calcium if the patient is not receiving supplemental calcium and is at risk for hypocalcemia, but balance this with the risk of hypercalcemia from calcium acetate.
* Patient education on symptoms of hypercalcemia is crucial.
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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.
