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# Calcium Acetate
## Overview
Calcium acetate is a phosphate binder used to control hyperphosphatemia in patients with chronic kidney disease (CKD) on dialysis. It works by binding to dietary phosphate in the gastrointestinal tract, preventing its absorption and promoting its excretion.
## Primary Indications
* Management of hyperphosphatemia in patients with end-stage renal disease (ESRD) who are undergoing dialysis.
## Adult Dosing
* **Initial dose:** 667 mg (equivalent to 169 mg elemental calcium or 13 mEq of calcium) administered orally with meals.
* **Titration:** Dosage should be individualized based on serum phosphate levels. Titrate dose gradually upwards, monitoring serum phosphate levels weekly.
* **Maximum dose:** No definitive maximum dose is established, but doses exceeding 4000 mg (approximately 3000 mg elemental calcium) per day are generally not recommended due to the risk of hypercalcemia. Doses are typically guided by phosphate control and calcium levels.
## Pediatric Dosing
* **Established pediatric dosing is not readily available.** Dosing in pediatric patients should be individualized and based on clinical response and monitoring of serum calcium and phosphate levels. Consultation with a pediatric nephrologist or pharmacist is recommended.
## Dose Adjustments
* **Hypercalcemia:** If serum calcium exceeds the desired range (typically >10.5 mg/dL or as per institutional guidelines), reduce the dose of calcium acetate or temporarily discontinue. Consider dietary calcium restriction.
* **Hypocalcemia:** If hypocalcemia occurs, increase the dose of calcium acetate or consider calcium supplementation.
## Contraindications
* Hypercalcemia.
* Hypersensitivity to calcium acetate.
* Conditions causing visceral calcification.
## Adverse Effects
* **Common:** Hypercalcemia, constipation, nausea, vomiting, abdominal pain.
* **Serious:** Severe hypercalcemia can lead to cardiac arrhythmias, confusion, delirium, coma, and renal failure. Vascular calcification may occur with long-term use, especially with inadequately controlled hyperphosphatemia and hypercalcemia.
## Key Drug Interactions
* **Tetracyclines and Quinolones:** Calcium acetate can decrease the absorption of these antibiotics. Separate administration by at least 2 hours.
* **Thyroid Hormones:** Calcium acetate can reduce the absorption of levothyroxine. Separate administration by at least 4 hours.
* **Bisphosphonates:** Concurrent use may decrease bisphosphonate absorption. Separate administration by at least 2 hours.
* **Calcium Channel Blockers:** Increased risk of hypercalcemia.
## Monitoring
* **Serum Phosphate:** Monitor regularly (weekly initially, then as clinically indicated) to assess efficacy and guide dose titration.
* **Serum Calcium:** Monitor regularly (at least 3 times per week during initial dose titration, then at least monthly) to prevent and manage hypercalcemia. Target range typically 8.4-9.5 mg/dL (or as per institutional guidelines).
* **Albumin:** Correct serum calcium for low albumin levels if used to assess calcium status.
* **Intact Parathyroid Hormone (iPTH):** Monitor as part of CKD mineral and bone disorder management.
## Clinical Pearls
* Administer calcium acetate **with meals** to maximize phosphate binding.
* Use caution in patients with a history of kidney stones.
* Ensure adequate dietary calcium restriction if needed to prevent hypercalcemia.
* When switching from other phosphate binders, consider the elemental calcium content and adjust dosing accordingly.
* Consider the cumulative calcium load from all sources (diet, supplements, binders) to avoid hypercalcemia and vascular calcification.
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**Disclaimer:** This information is intended for healthcare professionals and is not a substitute for professional medical advice. Always consult the most current prescribing information and your institution's protocols before making any clinical decisions. Dosing and recommendations may vary.
