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# Calcium acetate
## Overview
Calcium acetate is a phosphate binder used to manage hyperphosphatemia in patients with chronic kidney disease (CKD). It provides a high availability of calcium for binding dietary phosphate in the GI tract to form insoluble calcium phosphate, which is then excreted in feces.
## Primary Indications
* Reduction of serum phosphorus in patients with end-stage renal disease (ESRD).
## Adult Dosing
* **Initial Dose:** 1334 mg (two 667 mg capsules/tablets) orally with each meal.
* **Titration:** Adjust dose based on serum phosphate levels. Most patients require 2000 mg to 4000 mg per day.
* **Maximum:** Dosing is often restricted by the development of hypercalcemia.
## Pediatric Dosing
* **General:** Use is largely off-label and dependent on institutional protocols.
* **Typical Starting Range:** 667 mg per meal; adjust based on serum phosphate and total daily calcium intake targets. Consult a pediatric nephrologist for individualized titration.
## Dose Adjustments
* **Renal Impairment:** No dose adjustment necessary for CKD; however, reduce or hold dose if serum calcium exceeds the upper limit of normal or if the calcium-phosphate product (Ca x P) is persistently >55 mg²/dL².
## Contraindications
* Hypercalcemia.
* Hypophosphatemia.
* Renal calculi (calcium-containing stones).
## Adverse Effects
* **Common:** Hypercalcemia (manifesting as nausea, constipation, confusion, or cardiac arrhythmias), GI irritation, and flatulence.
* **Serious:** Metastatic soft tissue calcification (due to high calcium-phosphate product).
## Key Drug Interactions
* **Fluoroquinolones/Tetracyclines/Biphosphonates:** Calcium acetate significantly reduces the oral absorption of these drugs. Separate administration by at least 2–3 hours.
* **Levothyroxine:** Calcium binds levothyroxine; separate doses by at least 4 hours.
* **Thiazide Diuretics:** May cause increased serum calcium levels by reducing renal calcium excretion.
## Monitoring
* **Serum Phosphorus:** Monitor at least monthly during titration.
* **Serum Calcium:** Monitor weekly during dose titration, then monthly.
* **Calcium-Phosphate Product:** Maintain <55 mg²/dL².
* **Symptoms:** Watch for signs of hypercalcemia (constipation, abdominal pain, nausea, mental status changes).
## Clinical Pearls
* **Administration:** Must be taken with meals to effectively bind dietary phosphorus.
* **Calcium Load:** Because calcium acetate is a calcium-based binder, patients are at risk for hypercalcemia, particularly if also consuming vitamin D supplements or calcium-based antacids.
* **Efficacy:** Generally considered more phosphate-binding potent per gram of calcium received compared to calcium carbonate due to higher solubility.
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**Educational Disclaimer:** This information is for educational purposes only and does not constitute medical advice. Verify all dosages, contraindications, and drug interactions against institutional protocols and current manufacturer prescribing information before administration.
