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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 phosphorus in the gastrointestinal tract, forming an insoluble calcium phosphate precipitate that is then excreted.
## Primary Indications
* Treatment of hyperphosphatemia in patients with end-stage renal disease (ESRD) requiring dialysis.
## Adult Dosing
* **Initial Dose:** 667 mg (equivalent to 169 mg elemental calcium) orally with each meal.
* **Titration:** Dosage should be adjusted based on serum phosphorus levels. The goal is to maintain serum phosphorus below 6 mg/dL. Doses can be increased by 667 mg per meal increment.
* **Maximum Dose:** Doses up to 4000 mg (equivalent to 1013 mg elemental calcium) per day have been used, but higher doses increase the risk of hypercalcemia. The maximum dose should be guided by individual patient response and tolerance, with careful monitoring of serum calcium and phosphorus.
## Pediatric Dosing
* There is no established pediatric dosing for calcium acetate. Use in pediatric patients is generally not recommended due to lack of data and increased risk of adverse effects.
## Dose Adjustments
* **Renal Impairment:** Not applicable in the context of its primary indication (ESRD).
* **Hepatic Impairment:** No dose adjustment is typically necessary.
* **Hypercalcemia:** If hypercalcemia occurs, the dose of calcium acetate should be reduced or discontinued.
## Contraindications
* Hypercalcemia.
* Hypersensitivity to calcium acetate or any component of the formulation.
* Use in patients with adynamic bone disease or osteomalacia.
## Adverse Effects
* **Common:** Nausea, vomiting, constipation, diarrhea, abdominal pain.
* **Serious:** Hypercalcemia (symptoms include anorexia, nausea, vomiting, constipation, abdominal pain, polyuria, polydipsia, fatigue, weakness, hypertension, arrhythmias, confusion, stupor, coma), hypophosphatemia, aluminum toxicity (if co-administered with aluminum-containing products).
## Key Drug Interactions
* **Tetracyclines and Fluoroquinolones:** Calcium acetate can decrease the absorption of these antibiotics. Administer oral antibiotics at least 2 hours before or 6 hours after calcium acetate.
* **Thyroid Hormones:** Calcium acetate can decrease the absorption of levothyroxine. Separate administration by at least 4 hours.
* **Other Calcium-Containing Products:** Concurrent use can increase the risk of hypercalcemia.
## Monitoring
* **Serum Phosphorus:** Monitor regularly (e.g., weekly during initial titration, then monthly).
* **Serum Calcium:** Monitor regularly, especially during dose titration and in patients with a history of hypercalcemia.
* **PTH levels:** May be monitored as part of overall CKD mineral and bone disorder management.
* **Bicarbonate levels:** Monitor for potential metabolic alkalosis.
## Clinical Pearls
* Calcium acetate should be taken with meals to effectively bind dietary phosphorus.
* Patients should be educated on the signs and symptoms of hypercalcemia and to report them promptly.
* Co-administration with aluminum-containing antacids or laxatives should be avoided due to the risk of aluminum accumulation and toxicity.
* The amount of elemental calcium provided by calcium acetate is approximately 25% by weight.
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*Please verify the information with current prescribing information and relevant clinical guidelines.*
