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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 dietary phosphorus in the gastrointestinal tract, forming insoluble calcium phosphate, which is then excreted.
## Primary Indications
* Management of hyperphosphatemia in patients with end-stage renal disease (ESRD) on hemodialysis or peritoneal dialysis.
## Adult Dosing
* **Initial dose:** 667 mg (1 gram calcium acetate) orally with each meal.
* **Titration:** Doses should be individualized based on serum phosphorus levels. The goal is to reduce serum phosphorus to less than 6 mg/dL.
* **Typical maintenance dose:** 1332 mg to 2000 mg (2 to 3 grams calcium acetate) orally with meals.
* **Maximum dose:** No specific maximum dose is established, but doses are titrated to achieve therapeutic phosphorus control and avoid hypercalcemia. Patients may require up to 6-12 grams (4-8 grams calcium acetate) per day divided with meals.
## Pediatric Dosing
* Dosing in pediatric patients is not well established. Use with caution and monitor closely. Some sources suggest starting at 10-20 mg/kg/day of elemental calcium (equivalent to approximately 22-44 mg/kg/day of calcium acetate) divided with meals, titrating to achieve serum phosphorus goals.
## Dose Adjustments
* **Hypercalcemia:** If hypercalcemia occurs, reduce the dose or temporarily discontinue. Monitor serum calcium levels closely.
* **Concomitant medications:** Separate administration from other oral medications by at least 1 hour to avoid potential interactions.
## Contraindications
* Hypercalcemia.
* Hypersensitivity to calcium acetate or any component of the formulation.
* Use in patients with a history of kidney stones (calcium-containing).
## Adverse Effects
* **Common:** Hypercalcemia, constipation, nausea, vomiting, diarrhea, abdominal pain.
* **Serious:** Severe hypercalcemia (symptoms include anorexia, nausea, vomiting, constipation, abdominal pain, dizziness, lethargy, confusion, polyuria, polydipsia, muscle weakness, arrhythmias).
## Key Drug Interactions
* **Tetracyclines and quinolones:** Calcium acetate can decrease the absorption of these antibiotics. Separate administration by at least 1 hour.
* **Thyroid hormones:** Calcium acetate can decrease the absorption of levothyroxine. Separate administration by at least 4 hours.
* **Bisphosphonates:** Calcium can reduce the absorption of bisphosphonates. Separate administration by at least 2 hours before and 4 hours after.
* **Digitalis glycosides:** Hypercalcemia from calcium acetate can increase the risk of digitalis toxicity.
* **Calcium channel blockers:** The effect of calcium channel blockers may be reduced in the presence of hypercalcemia.
## Monitoring
* **Serum phosphorus:** Monitor regularly (e.g., every 2-4 weeks) to assess efficacy and guide dose titration.
* **Serum calcium:** Monitor regularly, especially during dose initiation and titration, and if symptoms of hypercalcemia develop. Target serum calcium levels are generally in the normal range.
* **Intact parathyroid hormone (iPTH):** Monitor as part of CKD mineral and bone disorder management.
## Clinical Pearls
* Calcium acetate is typically taken with meals to maximize phosphorus binding.
* Ensure adequate dietary calcium intake is considered when assessing total calcium load.
* Consider the potential for calcium-vitamin D interactions and the risk of extraskeletal calcification.
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*Disclaimer: This information is intended for healthcare professionals. Always consult the most current prescribing information and relevant clinical guidelines for definitive patient care decisions.*
