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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 binds to dietary phosphate in the gastrointestinal tract, preventing its absorption and thereby lowering serum phosphate levels.
## Primary Indications
* Treatment of hyperphosphatemia in patients with end-stage renal disease (ESRD).
## Adult Dosing
* **Dosage:** Dosing is individualized based on serum phosphate levels and dietary phosphate intake.
* **Starting Dose:** Typically initiated at 667 mg (elemental calcium 169 mg) with each meal.
* **Titration:** Dosage should be adjusted to maintain serum phosphate levels at or below 5.5 mg/dL.
* **Maximum Dose:** While not strictly defined by official guidelines, doses up to 4000 mg (elemental calcium 1024 mg) daily, divided with meals, have been used in clinical practice. Individualize based on patient response and tolerance.
## Pediatric Dosing
* Dosing for pediatric patients is not well-established. Use with caution and consider expert consultation.
## Dose Adjustments
* **Renal Impairment:** Not applicable as it is used in patients with ESRD.
* **Hepatic Impairment:** No specific dose adjustments are typically required.
## Contraindications
* Hypercalcemia.
* Hypersensitivity to calcium acetate or any component of the formulation.
* Patients with a history of calcium-containing kidney stones (relative contraindication, use with caution).
## Adverse Effects
* **Common:** Hypercalcemia, constipation, nausea, vomiting, diarrhea, dyspepsia.
* **Serious:** Severe hypercalcemia (symptoms include confusion, lethargy, cardiac arrhythmias, severe constipation, nausea, vomiting, abdominal pain), calciphylaxis (rare but serious).
## Key Drug Interactions
* **Tetracyclines and Fluoroquinolones:** Calcium acetate can decrease the absorption of these antibiotics. Administer at least 1 hour before or 3 hours after calcium acetate.
* **Thyroid Hormones (Levothyroxine):** Calcium acetate can reduce the absorption of levothyroxine. Separate administration by at least 4 hours.
* **Antacids:** Concurrent use may increase the risk of hypercalcemia.
* **Calcium Channel Blockers:** Potential for additive hypercalcemic effects.
* **Digoxin:** Hypercalcemia can potentiate cardiac toxicity of digoxin.
## Monitoring
* **Serum Phosphate:** Monitor regularly (e.g., before initiating, 1 week after dose changes, then monthly or quarterly depending on stability).
* **Serum Calcium:** Monitor regularly, especially at the initiation of therapy and with dose adjustments, to prevent or manage hypercalcemia.
* **Alkaline Phosphatase:** Monitor periodically.
* **BUN and Creatinine:** Monitor periodically.
## Clinical Pearls
* Administer calcium acetate with meals to effectively bind dietary phosphate.
* Monitor calcium levels closely as hypercalcemia is a common and significant adverse effect. If hypercalcemia occurs, reduce the dose or temporarily discontinue.
* If hypercalcemia persists despite dose reduction, consider switching to a non-calcium-based phosphate binder.
* Patient education on adherence, potential side effects, and the importance of monitoring is crucial.
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*This information is intended for clinical pharmacists and healthcare professionals. It is essential to consult the most current prescribing information and relevant clinical guidelines for definitive patient management.*
