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# Calcium acetate
## Overview
Calcium acetate is a phosphate-binding agent used to control hyperphosphatemia in patients with end-stage renal disease (ESRD). It is more soluble than calcium carbonate and provides a higher amount of elemental calcium per gram, resulting in efficient phosphate binding in the gastrointestinal tract.
## Primary Indications
Hyperphosphatemia in patients with chronic kidney disease (CKD) on dialysis.
## Adult Dosing
* **Initial Dose:** 1,334 mg (2 capsules or 1 tablet) taken orally with each meal.
* **Titration:** Adjust based on serum phosphate levels. Most patients require 2 to 4 capsules/tablets per meal to achieve target phosphate levels.
* **Maximum Dose:** There is no strict numerical maximum, but doses exceeding 6–8 tablets/day increase the risk of hypercalcemia.
## Pediatric Dosing
**Safety and efficacy not established.**
Dosing in pediatric patients is not standardized. If used, it is off-label and typically managed by pediatric nephrology based on serum phosphate targets and dietary intake. Specific dosing protocols must be obtained from institutional guidelines.
## Dose Adjustments
* **Renal Impairment:** Required; intended for use in ESRD. Close monitoring of serum calcium is essential.
* **Hepatic Impairment:** No specific adjustments defined.
## Contraindications
* Hypercalcemia.
* Hypophosphatemia.
* Known hypersensitivity to calcium components.
## Adverse Effects
* **Common:** Hypercalcemia, nausea, constipation.
* **Serious:** Metastatic calcification (if calcium-phosphate product is persistently high), vascular calcification.
## Key Drug Interactions
* **Fluoroquinolones/Tetracyclines:** Calcium significantly decreases absorption. Separate administration by at least 2–3 hours.
* **Levothyroxine:** Calcium interferes with absorption; space by at least 4 hours.
* **Bisphosphonates:** Reduces absorption of bisphosphonates; space doses.
* **Calcium-channel blockers:** May be antagonized by calcium supplements.
## Monitoring
* **Serum Phosphate:** Monitor every 2–4 weeks during initiation; adjust dose to maintain levels within the target range (typically 3.5–5.5 mg/dL per KDOQI guidelines).
* **Serum Calcium:** Monitor weekly during titration to prevent hypercalcemia.
* **Calcium-Phosphate Product (Ca x P):** Maintain <55 mg²/dL² to reduce cardiovascular risk.
## Clinical Pearls
* **Administration:** Must be taken **with meals** to bind dietary phosphorus. If a meal is missed, the dose should be skipped.
* **Elemental Calcium:** 667 mg of calcium acetate provides 169 mg of elemental calcium.
* **Hypercalcemia Risk:** Avoid concomitant use of calcium-based supplements or vitamin D analogues if serum calcium is elevated.
* **Patient Education:** Advise patients on a low-phosphorus diet; calcium acetate is not a replacement for dietary phosphorus restriction.
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**Educational Disclaimer:** This information is for educational purposes only. Clinical practice varies by institution. Always verify current prescribing information, clinical guidelines, and local hospital protocols before prescribing or administering medications. Consult a qualified healthcare professional for specific clinical decisions.
