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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, preventing its absorption. Each 500 mg tablet of calcium acetate contains approximately 12.5 mEq of elemental calcium.
## Primary Indications
* Management of hyperphosphatemia in patients with end-stage renal disease (ESRD).
## Adult Dosing
* **Initial dose:** 500 mg (one tablet) orally with each meal.
* **Titration:** Dosage should be adjusted based on serum phosphate levels. The goal is to maintain serum phosphate below 6 mg/dL.
* **Typical dose range:** 500 mg to 2500 mg (1 to 5 tablets) per meal, depending on dietary phosphate intake and serum phosphate levels.
* **Maximum dose:** Not definitively established, but doses exceeding 3000 mg (6 tablets) per meal are generally not recommended due to the risk of hypercalcemia and exceeding total daily calcium intake recommendations. Total daily elemental calcium intake from all sources (diet, supplements, medications) should generally not exceed 2000 mg.
## Pediatric Dosing
Dosing in pediatric patients is not well-established and should be determined by a specialist based on individual patient factors, serum phosphate levels, and calcium intake.
## Dose Adjustments
* **Renal Impairment:** Patients with CKD already have impaired renal function. Dose adjustments are primarily guided by serum phosphate and calcium levels.
* **Hepatic Impairment:** No specific dose adjustments are recommended.
## Contraindications
* Hypercalcemia.
* Hypersensitivity to calcium acetate.
* Concurrent use with IV calcium.
## Adverse Effects
* **Common:** Hypercalcemia (most significant), constipation, nausea, vomiting, abdominal pain.
* **Less Common:** Hypercalciuria, hypophosphatemia.
* **Symptoms of Hypercalcemia:** Anorexia, dry mouth, fatigue, headache, nausea, vomiting, constipation, polyuria, polydipsia, muscle weakness, bone pain, confusion, lethargy, cardiac arrhythmias.
## Key Drug Interactions
* **Tetracyclines and Quinolones:** Calcium acetate can decrease the absorption of these antibiotics. Separate administration by at least 2 hours (before or after).
* **Thyroid Hormones:** Calcium acetate can reduce the absorption of levothyroxine. Separate administration by at least 4 hours.
* **Digoxin:** Hypercalcemia may increase the risk of digoxin toxicity.
* **Vitamin D Analogs:** May increase the risk of hypercalcemia.
* **Calcium Channel Blockers:** Concurrent use may reduce their efficacy.
* **Aluminum-containing antacids:** Avoid concurrent use due to risk of aluminum toxicity.
## Monitoring
* **Serum Phosphate:** Monitor regularly to guide dosing and assess efficacy.
* **Serum Calcium:** Monitor regularly, especially when initiating therapy or increasing the dose, to prevent or manage hypercalcemia.
* **Total Calcium x Phosphate product:** Aim to keep below 55 mg²/dL².
* **Electrolytes:** Monitor electrolytes periodically.
* **Alkaline Phosphatase:** May be monitored.
## Clinical Pearls
* Administer calcium acetate with meals to maximize phosphate binding.
* Consider the total daily calcium intake from all sources to avoid exceeding 2000 mg of elemental calcium per day.
* Patients should be educated on symptoms of hypercalcemia and instructed to report them promptly.
* If hypercalcemia occurs, reduce the dose of calcium acetate or temporarily discontinue. If severe, discontinuation and supportive care are necessary.
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***Disclaimer:*** This information is intended for healthcare professionals. Always verify current prescribing information and consult with relevant resources before making clinical decisions. Dosing and recommendations may vary based on individual patient factors, institutional protocols, and evolving medical knowledge.
