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# Calcium Acetate
## Overview
Calcium acetate is an oral phosphate binder used in the management of hyperphosphatemia in patients with chronic kidney disease (CKD). It binds to dietary phosphate in the gastrointestinal tract, forming insoluble calcium phosphate, which is then excreted in the feces. Each gram of calcium acetate contains approximately 252 mg of elemental calcium.
## Primary Indications
* **Hyperphosphatemia** in patients with end-stage renal disease (ESRD).
## Adult Dosing
The starting dose is typically 667 mg (equivalent to 2 tablets of 333 mg each) administered with each meal. Doses should be titrated based on serum phosphate levels.
* **Starting Dose:** 667 mg orally with meals.
* **Titration:** Increase dose gradually as needed to control serum phosphate levels.
* **Typical Maintenance Dose:** 1333 mg to 2222 mg orally with meals, though doses up to 4000 mg per day (or higher in some cases) may be required. The maximum recommended daily dose is generally considered to be 4000 mg.
## Pediatric Dosing
Dosing in pediatric patients is not well established and should be individualized based on the patient's age, weight, and serum phosphate levels. Dosing should be guided by a nephrologist.
## Dose Adjustments
No specific dose adjustments are routinely recommended for hepatic impairment. For renal impairment, dose titration should be based on serum phosphate and calcium levels.
## Contraindications
* Hypercalcemia.
* Hypersensitivity to calcium acetate.
## Adverse Effects
* **Common:** Hypercalcemia, constipation, nausea, vomiting, abdominal pain.
* **Serious:** Calciphylaxis (rare), adynamic bone disease.
## 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 can decrease the absorption of levothyroxine. Administer at least 4 hours apart.
* **Bisphosphonates:** Calcium can reduce the absorption of bisphosphonates. Administer at least 2 hours before or 6 hours after calcium acetate.
* **Antacids:** Concurrent use may increase the risk of hypercalcemia.
## Monitoring
* **Serum Phosphate:** Regularly monitor serum phosphate levels to guide dose titration. Target levels are typically < 5.5 mg/dL in patients with ESRD.
* **Serum Calcium:** Regularly monitor serum calcium levels. Target levels are typically < 10.5 mg/dL or within the laboratory's normal range.
* **Bicarbonate:** Monitor for potential metabolic alkalosis, although this is less common with acetate salts compared to calcium carbonate.
* **Alkaline Phosphatase:** Monitor periodically, especially in pediatric patients and those with CKD to assess for bone disease.
## Clinical Pearls
* Administer calcium acetate with meals to maximize phosphate binding.
* Titrate dose based on both serum phosphate and serum calcium levels to avoid hypercalcemia. If hypercalcemia occurs, reduce the dose or temporarily discontinue the medication.
* In patients taking other medications that can be affected by calcium absorption (e.g., certain antibiotics, thyroid hormones), separate administration by appropriate time intervals.
* Patients with CKD may have altered vitamin D metabolism; monitor calcium and phosphate levels closely.
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*This information is intended for healthcare professionals. Always consult the most current prescribing information or your institution's formulary for complete details and to verify dosing and safety information before making clinical decisions. Dosing may vary based on individual patient factors and local protocols.*
