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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 more effective milligram-for-milligram than calcium carbonate because it contains less elemental calcium while providing higher phosphate-binding capacity per unit of salt.
## Primary Indications
* Reduction of serum phosphorus in patients with end-stage renal disease (ESRD) on hemodialysis.
## Adult Dosing
* **Initial Dose:** 2 capsules or tablets per meal.
* **Titration:** Adjust based on serum phosphate levels. Most patients require 3–4 capsules/tablets per meal to achieve target phosphorus levels.
* **Maximum Dose:** Generally avoid exceeding 1500 mg of elemental calcium per day from all sources to minimize hypercalcemic risk.
## Pediatric Dosing
* **Safety/Efficacy:** Established data is limited. Dosing should be determined by a pediatric nephrologist based on local protocol and severity of hyperphosphatemia.
* **Typical initiation:** Often ranges from 25–50 mg/kg/day divided with meals, though precise titration is required to avoid hypercalcemia.
## Dose Adjustments
* **Renal Impairment:** No specific adjustment required; it is the medication of choice for ESRD.
* **Hypercalcemia:** If serum calcium levels rise, decrease the dose or switch to a non-calcium-based phosphate binder (e.g., sevelamer, lanthanum).
## Contraindications
* Hypercalcemia.
* Known hypersensitivity to calcium salts.
## Adverse Effects
* **Common:** Hypercalcemia, nausea, constipation, vomiting.
* **Serious:** Metastatic calcification (if calcium-phosphorus product > 55 mg²/dL²), severe hypercalcemia symptoms (confusion, cardiac arrhythmias).
## Key Drug Interactions
* **Quinolones/Tetracyclines:** Calcium significantly decreases absorption. Separate administration by at least 2 hours before or 6 hours after.
* **Levothyroxine:** Oral calcium can decrease absorption. Separate by at least 4 hours.
* **Bisphosphonates:** Separate by at least 2 hours to prevent reduced absorption.
* **Iron Supplements:** Calcium can inhibit iron absorption; monitor efficacy.
## Monitoring
* **Serum Phosphorus:** Monitor periodically; target levels depend on KDIGO guidelines (typically 3.5–5.5 mg/dL).
* **Serum Calcium:** Monitor weekly during initiation and dose titration.
* **Calcium-Phosphorus Product:** Monitor to assess risk of calcification; keep < 55 mg²/dL².
## Clinical Pearls
* **Administration:** Must be taken with meals to bind dietary phosphorus. It has no effect if taken on an empty stomach.
* **Elemental Calcium:** Each 667 mg calcium acetate tablet provides 169 mg of elemental calcium.
* **Hypercalcemia Risk:** Monitor for signs of hypercalcemia (nausea, vomiting, lethargy, cardiac arrhythmias), especially if the patient is also taking Vitamin D analogs (e.g., calcitriol), which increase calcium absorption.
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**Educational Disclaimer:** This information is for educational purposes only. Clinical practice is subject to change. Always verify current prescribing information, institutional protocols, and patient-specific needs with a qualified healthcare professional or the package insert before prescribing or administering medication.
