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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.
## Primary Indications
* **Hyperphosphatemia in patients with chronic kidney disease on dialysis.**
## Adult Dosing
* **Initial:** 667 mg (13.5 mEq elemental calcium) orally with each meal.
* **Titration:** Dosage should be adjusted based on serum phosphate levels. Typical target serum phosphate is less than 5.5 mg/dL.
* **Maximum:** The manufacturer states no specific maximum dose, but clinical efficacy and tolerability should guide therapy. Doses up to 3000 mg (61 mEq elemental calcium) per day have been used in some studies.
## Pediatric Dosing
* Dosing in pediatric patients has not been established. Use is not generally recommended.
## Dose Adjustments
* No specific dose adjustments are recommended for hepatic impairment.
* Dose should be adjusted based on serum phosphate and calcium levels. Monitor calcium levels closely, especially in patients with decreased renal function, to avoid hypercalcemia.
## Contraindications
* Hypercalcemia.
* Hypersensitivity to calcium acetate or any component of the formulation.
## Adverse Effects
* **Common:** Hypercalcemia, nausea, vomiting, constipation, diarrhea.
* **Serious:** Severe hypercalcemia (symptoms include anorexia, dry mouth, metallic taste, nausea, vomiting, constipation, abdominal pain, muscle weakness, decreased libido, fatigue, headache, confusion, polyuria, polydipsia, and cardiac arrhythmias). Vascular calcification.
## Key Drug Interactions
* **Tetracyclines and Fluoroquinolones:** Calcium acetate can decrease the absorption of these antibiotics. Administer antibiotics at least 2 hours before or 3 hours after calcium acetate.
* **Thyroid Hormones:** Calcium acetate can decrease the absorption of thyroid hormones. Separate administration by at least 4 hours.
* **Ketoconazole:** Calcium acetate can decrease ketoconazole absorption. Administer ketoconazole at least 2 hours before calcium acetate.
* **Cation-Exchange Binders (e.g., sevelamer, lanthanum):** Concurrent use may potentially reduce the absorption of calcium acetate or the binder. Clinical significance is uncertain, but separation of doses may be considered if concerns arise.
* **Digitalis Glycosides:** Hypercalcemia can potentiate digitalis toxicity.
## Monitoring
* **Serum Phosphate:** Monitor regularly (e.g., every 1-2 weeks initially, then monthly or quarterly as stable) to assess efficacy and guide dose titration.
* **Serum Calcium:** Monitor regularly. Target serum calcium levels should be maintained within the normal range (e.g., <10.5 mg/dL, though some sources suggest up to 11.5 mg/dL depending on patient population and physician preference). Correct for serum albumin if necessary.
* **Alkaline Phosphatase:** Monitor periodically.
* **Aluminum, Calcium, and Magnesium Levels:** Monitor periodically.
## Clinical Pearls
* Administer calcium acetate with meals to effectively bind dietary phosphate.
* Monitor serum calcium closely. If hypercalcemia occurs, reduce the dose of calcium acetate or discontinue temporarily. If hypercalcemia persists, consider the possibility of concurrent calcium or vitamin D therapy.
* Ensure patients are advised not to take other medications within 2 hours before or 3 hours after calcium acetate, especially antibiotics like tetracyclines and fluoroquinolones, and thyroid hormones.
* Consider the total daily elemental calcium intake from all sources (diet, supplements, phosphate binders) to prevent cumulative hypercalcemia.
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*Disclaimer: This information is intended for healthcare professionals. Always consult the most current prescribing information and institutional protocols for complete details. Verify current prescribing information before making clinical decisions.*
