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# Calcium acetate
## Overview
Calcium acetate is a phosphate binder used to manage hyperphosphatemia in patients with end-stage renal disease (ESRD). It is highly soluble and provides calcium ions that bind to 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:** 1,334 mg (two 667 mg capsules/tablets) orally with each meal.
* **Titration:** Increase or decrease dosage based on serum phosphate levels.
* **Maximum:** Typically 1,334 mg per meal (4,002 mg/day). Doses exceeding this are rarely needed; clinical protocols vary by facility regarding daily limits.
## Pediatric Dosing
Safety and efficacy have not been established in pediatric patients. Use is off-label and requires nephrology consultation. Dosing is typically individualized based on serum phosphate levels and dietary intake.
## Dose Adjustments
* **Hypercalcemia:** If serum calcium levels rise, decrease dosage or temporarily discontinue.
* **Renal Impairment:** Contraindicated in patients with hypercalcemia.
## Contraindications
* Hypercalcemia.
* Hypophosphatemia.
## Adverse Effects
* **Common:** Hypercalcemia, nausea, vomiting, constipation, and abdominal pain.
* **Serious:** Potential for accelerated vascular/soft tissue calcification if serum calcium-phosphorus product exceeds 55 mg²/dL².
## Key Drug Interactions
* **Tetracyclines/Quinolones:** Calcium acetate inhibits absorption. Administer at least 2 hours before or 6 hours after these antibiotics.
* **Levothyroxine:** Reduces absorption. Separate administration by at least 4 hours.
* **Bisphosphonates:** Reduces oral bioavailability. Separate dosing significantly.
* **Calcium-channel blockers:** Potential for reduced effectiveness due to calcium antagonism.
## Monitoring
* **Serum Phosphorus:** Monitor weekly during initiation and dose titration.
* **Serum Calcium:** Monitor weekly initially. If hypercalcemia develops, discontinue or reduce dose.
* **Calcium-Phosphorus Product:** Keep <55 mg²/dL² to minimize the risk of metastatic calcification.
## Clinical Pearls
* **Timing:** Must be taken with meals to effectively bind dietary phosphorus.
* **Comparison:** Offers a higher calcium-to-phosphate binding ratio compared to calcium carbonate, but carries a higher risk of hypercalcemia.
* **Adherence:** Pill burden is often high; counsel patients on the necessity of dosing with every meal to prevent secondary hyperparathyroidism.
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**Educational Disclaimer:** This information is for educational purposes only. Always verify drug doses, contraindications, and interaction profiles via the current package insert, institutional formulary, or clinical decision support software before prescribing or administering medication.
