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# Calcium acetate
## Overview
Calcium acetate is a phosphate binder used to reduce serum phosphorus in patients with end-stage renal disease (ESRD). It is highly soluble and provides more elemental calcium per milligram than calcium carbonate, often requiring fewer tablets to achieve the same degree of phosphate binding.
## Primary Indications
Hyperphosphatemia in patients with end-stage renal disease (ESRD).
## Adult Dosing
* **Initial:** 1,334 mg (two 667 mg capsules/tablets) orally with each meal.
* **Titration:** Adjust based on serum phosphate levels. Most patients require 2,000 mg to 4,000 mg of elemental calcium daily (delivered via 3–4 doses per meal).
* **Maximum:** Doses exceeding 3,000 mg (as elemental calcium) per day increase the risk of hypercalcemia.
## Pediatric Dosing
Safety and efficacy have not been established in pediatric patients. Use is off-label and should be guided by pediatric nephrology protocols. Starting doses are often weight-based or calculated to provide specific elemental calcium amounts per meal; verify with local institutional guidelines.
## Dose Adjustments
* **Renal Impairment:** No formal adjustment for ESRD; it is the primary target population.
* **Hypercalcemia:** If serum calcium levels rise, decrease or temporarily discontinue the dose.
## Contraindications
* Hypercalcemia.
* Hypophosphatemia.
* Known hypersensitivity to calcium acetate.
## Adverse Effects
* **Common:** Hypercalcemia, nausea, vomiting, constipation, abdominal pain.
* **Serious:** Metastatic calcification (if hypercalcemia and high calcium-phosphate product persist), pruritus.
## Key Drug Interactions
* **Tetracyclines/Quinolones:** Calcium binds to these antibiotics, significantly reducing absorption. Administer at least 2 hours before or 6 hours after calcium acetate.
* **Levothyroxine:** Calcium interferes with absorption. Separate administration by at least 4 hours.
* **Bisphosphonates:** Calcium reduces absorption; separate doses significantly.
## Monitoring
* **Serum Phosphorus:** Monitor at baseline and periodically (typically monthly during initial titration).
* **Serum Calcium:** Monitor weekly during dose titration, then periodically.
* **Calcium-Phosphate Product (Ca x P):** Calculate to assess risk of metastatic calcification; aim for < 55 mg²/dL².
## Clinical Pearls
* **Timing is Critical:** Must be taken with meals to effectively bind dietary phosphorus. It has minimal efficacy if taken on an empty stomach.
* **Elemental Content:** 667 mg of calcium acetate provides approximately 169 mg of elemental calcium.
* **Avoid Vitamin D Overuse:** Monitor active Vitamin D analog therapy closely, as it increases calcium absorption and further elevates hypercalcemia risk.
* **Patient Education:** Advise patients to notify their provider of constipation, nausea, or signs of hypercalcemia (confusion, fatigue, excessive thirst).
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**Educational Disclaimer:** This information is for educational purposes only. Clinical practice varies by institution. Always verify dosages, contraindications, and drug-drug interaction alerts against the most current prescribing information or your facility's clinical pharmacy protocols before prescribing or administering medication.
