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# Calcium Acetate
## Overview
Calcium acetate is a calcium salt used primarily as a phosphate binder. It provides higher elemental calcium content per weight and greater phosphate-binding capacity compared to calcium carbonate, especially at lower gastric pH. Each 667 mg capsule/tablet contains 169 mg of elemental calcium.
## Primary Indications
Hyperphosphatemia in patients with end-stage renal disease (ESRD).
## Adult Dosing
Initiate with 2 capsules/tablets (1,334 mg) with each meal. Titrate based on serum phosphate levels to achieve target goal (typically <5.5 mg/dL). Most patients require 3–4 capsules/tablets per meal. Maximum dose typically does not exceed 12 capsules/tablets daily due to hypercalcemia risk.
## Pediatric Dosing
Safety and efficacy have not been established by the FDA. Dosing is off-label and varies significantly by local institutional protocol; typically titrated based on dietary phosphate intake and serum monitoring.
## Dose Adjustments
* **Renal Impairment:** No dose adjustment necessary for ESRD; however, reduce dose if persistent hypercalcemia develops.
* **Hypercalcemia:** Hold dose if serum calcium exceeds 10.5 mg/dL or if the Calcium-Phosphorus (Ca x P) product exceeds 55 mg²/dL².
## Contraindications
* Hypercalcemia.
* Hypophosphatemia.
* Nephrolithiasis (calcium-containing stones).
## Adverse Effects
* **Common:** Hypercalcemia, constipation, nausea, vomiting.
* **Serious:** Metastatic calcification (if Ca x P product is consistently elevated), vascular calcification.
## Key Drug Interactions
* **Quinolones/Tetracyclines:** Calcium significantly decreases absorption. Separate administration by at least 2–4 hours.
* **Levothyroxine:** Calcium interferes with absorption. Separate by at least 4 hours.
* **Bisphosphonates:** Calcium reduces absorption. Take bisphosphonates first and separate by at least 2 hours.
* **Iron salts:** Calcium interferes with iron absorption.
## Monitoring
* **Serum Calcium:** Weekly during initiation/titration, then monthly.
* **Serum Phosphate:** Monthly.
* **Ca x P Product:** Monitor regularly to reduce risk of soft tissue calcification.
## Clinical Pearls
* **Timing:** Must be taken with meals to effectively bind dietary phosphate.
* **Calcium Overload:** Avoid concurrent use of other calcium-containing supplements or calcium-based antacids.
* **Patient Education:** Advise patients that calcium acetate is a "binder," not a calcium supplement for bone health; it must be taken while consuming food to be effective.
* **Constipation:** If constipation occurs, ensure adequate fluid intake or discuss a stool softener with the provider.
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**Disclaimer:** This information is for educational purposes only. Clinical practice varies by institution and patient-specific factors. Always verify current prescribing information, dosing protocols, and contraindications via official resources (e.g., package insert, Lexicomp, or UpToDate) before administering medication.
