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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.
## Primary Indications
* Treatment of hyperphosphatemia in patients with end-stage renal disease (ESRD).
## Adult Dosing
* **Dosage is individualized based on serum phosphate levels.**
* **Starting Dose:** Typically 1330 mg (1000 mg elemental calcium) orally with meals.
* **Titration:** Increase dose gradually based on serum phosphate levels, usually by 1 to 2 tablets per meal.
* **Maximum Dose:** Generally not to exceed 10,000 mg (7500 mg elemental calcium) per day, but individual needs may vary. Doses up to 15000 mg (11250 mg elemental calcium) per day have been used, but with increased risk of hypercalcemia.
* **Administration:** Must be taken with meals to effectively bind dietary phosphate. Tablets should be chewed thoroughly before swallowing.
## Pediatric Dosing
* **Information is limited and not well established.** Dosing should be individualized and carefully monitored by a physician experienced in pediatric nephrology.
* Some sources suggest starting doses around 10-12 mg/kg/day of elemental calcium divided with meals, titrating based on phosphate levels.
## Dose Adjustments
* **Renal Impairment:** Not applicable as it is primarily used in CKD patients. However, monitor for hypercalcemia and metabolic alkalosis.
* **Hepatic Impairment:** No specific dose adjustments are typically required.
## Contraindications
* Hypercalcemia.
* Conditions causing hypercalcemia, such as sarcoidosis, primary hyperparathyroidism, and certain malignancies.
* Concomitant use of other calcium-containing products that could lead to additive calcium load.
## Adverse Effects
* **Common:** Hypercalcemia (most significant risk), nausea, vomiting, constipation, diarrhea.
* **Less Common:** Metabolic alkalosis, hypophosphatemia, abdominal pain, dry mouth.
* **Serious:** Vascular calcification, cardiac arrhythmias (secondary to hypercalcemia).
## Key Drug Interactions
* **Tetracyclines and Quinolones:** Calcium acetate can decrease the absorption of these antibiotics. Administer at least 2 hours before or 6 hours after these drugs.
* **Thyroid Hormones (Levothyroxine):** Calcium can decrease absorption. Separate administration by at least 4 hours.
* **Bisphosphonates:** Calcium may reduce the absorption of bisphosphonates. Separate administration by at least 2 hours.
* **Digoxin:** Hypercalcemia can increase the risk of digoxin toxicity.
* **Thiazide Diuretics:** May increase the risk of hypercalcemia.
* **Antacids:** Concurrent use can increase calcium absorption and risk of hypercalcemia.
## Monitoring
* **Serum Calcium:** Regularly monitor serum calcium levels, especially during initiation and dose titration. Corrected calcium should be maintained within the target range for CKD patients (often < 11 mg/dL or < 2.75 mmol/L, but consult local guidelines).
* **Serum Phosphate:** Monitor regularly to assess efficacy.
* **Serum Magnesium and Alkaline Phosphatase:** May be monitored periodically.
* **Signs and Symptoms of Hypercalcemia:** Educate patients to report symptoms such as nausea, vomiting, constipation, confusion, bone pain, and frequent urination.
## Clinical Pearls
* Chew tablets thoroughly to maximize phosphate binding.
* Administer with meals for optimal efficacy.
* The goal of therapy is to reduce serum phosphate levels, not necessarily to normalize serum calcium. However, hypercalcemia is a significant risk and requires careful monitoring.
* When switching from other phosphate binders, calculate the equivalent elemental calcium dose.
* If a patient develops hypercalcemia, reduce the dose or temporarily discontinue calcium acetate and consider reducing other calcium sources.
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*Please verify current prescribing information for the most up-to-date dosing, indications, and contraindications.*
