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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
* Management of hyperphosphatemia in patients with end-stage renal disease (ESRD).
## Adult Dosing
* **Initiation:** Typically started at 667 mg (13.3 mEq elemental calcium) orally with meals.
* **Titration:** Doses are adjusted based on serum phosphate levels. Doses can be increased up to 1333 mg (26.7 mEq elemental calcium) or 2000 mg (40 mEq elemental calcium) per meal, depending on the formulation and patient response.
* **Maximum:** Doses vary by formulation. For some oral formulations, the maximum recommended dose is 2000 mg per meal, equating to 40 mEq elemental calcium per meal. For intravenous administration (less common), doses are typically 2 mEq/kg to 4 mEq/kg.
## Pediatric Dosing
* Dosing in pediatric patients is not well-established and should be individualized by a specialist. Available data suggests starting doses around 1-2 mEq/kg/day divided with meals, titrating to target serum phosphate.
## Dose Adjustments
* **Renal Impairment:** Dose adjustment is based on serum phosphate and calcium levels. Monitor closely.
* **Hepatic Impairment:** No specific dose adjustments are typically required.
## Contraindications
* Hypercalcemia.
* Hypersensitivity to calcium acetate or any component of the formulation.
* Concomitant use of intravenous calcium acetate with digitalis glycosides due to the risk of severe cardiac arrhythmias.
## Adverse Effects
* **Common:** Hypercalcemia, nausea, vomiting, constipation, diarrhea, abdominal pain, headache.
* **Serious:** Development of adynamic bone disease (with long-term use), vascular calcification, severe hypercalcemia leading to cardiac arrhythmias, hypotension, coma.
## Key Drug Interactions
* **Tetracyclines and Fluoroquinolones:** Calcium acetate can decrease the absorption of these antibiotics by forming chelates. Separate administration by at least 2 hours.
* **Thyroid Hormones:** Calcium acetate can reduce the absorption of levothyroxine. Separate administration by at least 4 hours.
* **Antacids:** Concurrent use may increase the risk of hypercalcemia.
* **Fat-Soluble Vitamins (A, D, E, K):** May decrease absorption.
* **Digoxin:** Hypercalcemia from any source increases the risk of digoxin toxicity. Intravenous calcium acetate is contraindicated with digoxin.
## Monitoring
* **Serum Phosphate:** Monitor regularly (e.g., within weeks of initiation or dose change, then monthly) to assess efficacy.
* **Serum Calcium:** Monitor frequently, especially with dose titration, to prevent hypercalcemia. Target serum calcium levels are generally 8.0-10.0 mg/dL.
* **Serum Magnesium and Alkaline Phosphatase:** May be monitored periodically.
## Clinical Pearls
* Administer with meals to maximize phosphate binding.
* Monitor serum calcium and phosphate closely, as these are often abnormal in CKD patients.
* Educate patients about the importance of taking the medication with food and to report symptoms of hypercalcemia (e.g., nausea, vomiting, constipation, abdominal pain, confusion, lethargy).
* Be aware of potential for aluminum toxicity if used concurrently with aluminum-containing antacids.
This information is intended for healthcare professionals. Always consult the most current prescribing information and institutional protocols before making clinical decisions.
