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# Calcium Acetate
## Overview
Calcium acetate is a phosphate binder that reacts with dietary phosphate in the GI tract to form insoluble calcium phosphate, which is excreted in feces. It provides a higher calcium content per gram compared to other calcium salts (e.g., calcium carbonate).
## Primary Indications
* Control of hyperphosphatemia in patients with end-stage renal disease (ESRD) on hemodialysis or peritoneal dialysis.
## Adult Dosing
* **Initial Dose:** 2 capsules or 1,334 mg (approx. 340 mg elemental calcium) with each meal.
* **Titration:** Adjust based on serum phosphorus levels. Titrate up in increments of 1 capsule per meal as needed.
* **Typical Maintenance:** 2–4 capsules per meal.
* **Maximum:** Doses exceeding 12 capsules (8,004 mg) per day are generally avoided without close monitoring to prevent hypercalcemia.
## Pediatric Dosing
* **General:** Use is off-label and infrequent in pediatrics. Dosing is highly individualized based on serum phosphorus and total calcium load.
* **Typical Starting Range:** 20–50 mg/kg/day (total salt weight) divided with meals. Consult a pediatric nephrologist for specific practice-based protocols.
## Dose Adjustments
* **Renal Impairment:** Standard indication is for renal failure; no adjustment required, but monitor for hypercalcemia frequently.
* **Hypercalcemia:** If corrected serum calcium exceeds 10.5 mg/dL (or per facility specific range), reduce dose, switch to a non-calcium-based binder (e.g., sevelamer, lanthanum), or discontinue.
## Contraindications
* Hypercalcemia.
* Hypophosphatemia.
* Known hypersensitivity to calcium acetate.
## Adverse Effects
* **Common:** Hypercalcemia, nausea, vomiting, constipation, abdominal pain.
* **Serious:** Metastatic calcification (vascular or soft tissue) if calcium-phosphorus product (Ca x P) is consistently >55 mg²/dL².
## Key Drug Interactions
* **Tetracyclines/Fluoroquinolones/Bisphosphonates:** Calcium reduces absorption. Administer at least 2 hours before or 6 hours after these medications.
* **Levothyroxine:** Separate by at least 4 hours.
* **Iron Salts:** Calcium decreases iron absorption; separate doses by 2 hours.
## Monitoring
* **Serum Phosphorus:** Every 2–4 weeks during titration, then monthly to quarterly.
* **Serum Calcium:** Weekly during initial titration, then monthly to quarterly.
* **Calcium-Phosphorus Product:** Calculate regularly; aim to maintain <55 mg²/dL².
## Clinical Pearls
* Must be taken with meals to be effective as a phosphate binder.
* Monitor total daily calcium intake (including dietary sources and binder load) to minimize risk of vascular calcification.
* If hypercalcemia occurs, consider the total intake of Vitamin D supplements or high-calcium diet, as these exacerbate calcium absorption.
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*Disclaimer: This information is for educational purposes only. Clinical protocols and safety guidelines vary by institution. Always verify dosages, contraindications, and drug interactions against institutional formularies or current prescribing information (package insert) before prescribing or administering.*
