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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 binds to dietary phosphate in the gastrointestinal tract, forming insoluble calcium phosphate that is then excreted in the feces.
## Primary Indications
* Hyperphosphatemia in patients with end-stage renal disease (ESRD).
## Adult Dosing
Dosing is highly individualized based on serum phosphate levels and patient response.
* **Initial dose:** 667 mg (13.3 mEq elemental calcium) orally with meals.
* **Titration:** Increase dose gradually to reduce serum phosphate levels to target range (typically 3.5-5.5 mg/dL).
* **Maximum dose:** Generally not to exceed 4000 mg (80 mEq elemental calcium) per day. Doses higher than this are typically not recommended due to risk of hypercalcemia.
## Pediatric Dosing
There is limited established pediatric dosing. Dosing is typically initiated at 10-15 mg/kg/day of elemental calcium, divided into 3 doses with meals, and titrated to achieve serum phosphate control. Close monitoring for hypercalcemia and adherence is crucial.
## Dose Adjustments
* **Renal Impairment:** Not applicable as it's primarily used in ESRD patients. Dose should be adjusted based on serum calcium and phosphate levels.
* **Hepatic Impairment:** No specific adjustments are generally needed.
## Contraindications
* Hypercalcemia (serum calcium > 10.5 mg/dL or adjusted calcium > 11 mg/dL).
* Hypersensitivity to calcium acetate.
* Concurrent use with IV calcium.
## Adverse Effects
* **Common:** Hypercalcemia, constipation, nausea, vomiting, abdominal pain.
* **Serious:** Vascular calcification, cardiac arrhythmias (secondary to hypercalcemia), soft tissue calcification.
## Key Drug Interactions
* **Tetracyclines and Fluoroquinolones:** Calcium acetate can decrease absorption. Separate administration by at least 2 hours.
* **Thyroid Hormones (Levothyroxine):** Calcium acetate can decrease absorption. Separate administration by at least 4 hours.
* **Antacids containing magnesium or aluminum:** May increase the risk of hypermagnesemia or aluminum toxicity, respectively.
* **Digoxin:** Hypercalcemia can potentiate digoxin toxicity.
* **Thiazide Diuretics:** May increase the risk of hypercalcemia.
## Monitoring
* **Serum Phosphate:** Monitor regularly (frequency determined by clinical status and institutional protocol) to assess efficacy and guide dosing.
* **Serum Calcium:** Monitor regularly to prevent and detect hypercalcemia.
* **Intact Parathyroid Hormone (iPTH):** Monitor periodically as part of CKD-MBD management.
* **Alkaline Phosphatase:** Monitor periodically.
## Clinical Pearls
* Administer calcium acetate *with meals* to effectively bind dietary phosphate.
* Adjust dosage based on *both* serum phosphate and serum calcium levels. Target serum calcium is typically the upper limit of the normal range (e.g., 9.5-10.5 mg/dL) to maximize phosphate binding while minimizing hypercalcemia risk.
* For patients on hemodialysis, administer doses with each meal and monitor serum calcium and phosphate levels frequently, often post-dialysis.
* The elemental calcium content of calcium acetate is approximately 25%.
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**Disclaimer:** This information is intended for healthcare professionals. Always consult the most current prescribing information and relevant guidelines for complete and up-to-date drug information.
