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# Calcium Acetate
## Overview
Calcium acetate is a phosphate binder used primarily in patients with end-stage renal disease (ESRD). It is highly soluble and provides a high concentration of elemental calcium to complex with dietary phosphate in the gut, forming insoluble calcium phosphate, which is then excreted in feces.
## Primary Indications
* Reduction of serum phosphorus in patients with end-stage renal disease.
## Adult Dosing
* **Initial Dose:** 2 capsules (1334 mg) or 1 tablet (667 mg) with each meal.
* **Titration:** Adjust based on serum phosphorus levels to target a goal typically < 5.5 mg/dL.
* **Maximum Dose:** Generally titration continues until phosphorus control is achieved; however, clinicians should monitor for hypercalcemia.
## Pediatric Dosing
* **Safety/Efficacy:** Established data is limited. Dosing is typically extrapolated from adult titration guidelines based on phosphate levels.
* **Typical Starting Range:** 20–50 mg/kg/day divided with meals, pending facility-specific protocols and consultation with a pediatric nephrologist.
## Dose Adjustments
* **Renal Impairment:** Indicated for ESRD. No dose adjustment required, but patients are at higher risk for hypercalcemia if they have low bone turnover or are on high-dose vitamin D analogs.
* **Hepatic Impairment:** No specific adjustments defined.
## Contraindications
* Hypercalcemia.
* Hypophosphatemia.
## Adverse Effects
* **Common:** Hypercalcemia, nausea, vomiting, constipation, and abdominal pain.
* **Serious:** Metastatic calcification (associated with high calcium-phosphorus product > 55 mg²/dL²).
## Key Drug Interactions
* **Tetracyclines/Fluoroquinolones:** Calcium binds these medications, significantly reducing absorption. Separate administration by at least 2–3 hours.
* **Levothyroxine:** Calcium decreases absorption; separate by at least 4 hours.
* **Vitamin D/Analogs:** Increases calcium absorption; may necessitate dose reduction to prevent hypercalcemia.
## Monitoring
* **Serum Phosphorus:** Monitor every 2–4 weeks during titration.
* **Serum Calcium:** Monitor weekly during initiation and dose titration.
* **Calcium-Phosphorus Product:** Keep < 55 mg²/dL² to minimize the risk of soft tissue calcification.
## Clinical Pearls
* **Timing:** Must be taken with meals to effectively bind dietary phosphorus. Taking it between meals is ineffective for phosphate control.
* **Elemental Calcium:** 667 mg of calcium acetate provides 169 mg of elemental calcium.
* **Hypercalcemia Risk:** Monitor for signs such as confusion, weakness, or cardiac arrhythmias. Patients on dialysis may require adjustment of dialysate calcium concentrations if hypercalcemia persists.
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**Educational Disclaimer:** This information is for educational purposes only and does not constitute medical advice. Always verify current prescribing information, institutional protocols, and patient-specific factors with verified drug references (e.g., Lexicomp, UpToDate) and local clinical guidelines before administering medication.
