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# Calcium Acetate
## Overview
Calcium acetate is a phosphate binder used primarily to manage hyperphosphatemia in patients with end-stage renal disease (ESRD). It provides a higher calcium content per gram than other salts (like calcium carbonate) and is highly soluble, making it effective at lower doses for binding dietary phosphate in the gut.
## Primary Indications
* Control of hyperphosphatemia in adult and pediatric patients with end-stage renal disease (ESRD) on hemodialysis.
## Adult Dosing
* **Initial Dose:** 2 capsules or 1334 mg (tablet) with each meal.
* **Titration:** Adjust based on serum phosphate levels. Most patients require 3–4 capsules/tablets per meal to achieve target phosphate levels.
* **Maximum:** Doses exceeding 3,000 mg of elemental calcium daily are generally discouraged due to the risk of hypercalcemia.
## Pediatric Dosing
* **Dosing:** Not formally established by FDA; clinical practice typically involves lower, weight-based titration.
* **Starting Range:** 500 mg to 1000 mg per day, divided with meals. Dosing should be titrated to serum phosphate targets while monitoring serum calcium carefully to prevent hypercalcemia. Always consult institutional/pediatric nephrology protocols.
## Dose Adjustments
* **Hypercalcemia:** If calcium levels rise above the upper limit of normal, reduce the dose or switch to a non-calcium-based phosphate binder (e.g., sevelamer, lanthanum).
* **Advanced Chronic Kidney Disease:** Use with caution in patients with stages 3–4 CKD not on dialysis without strict monitoring; risk of metastatic calcification is significant.
## Contraindications
* Hypercalcemia.
* Hypophosphatemia.
* Known hypersensitivity to calcium acetate or excipients.
## Adverse Effects
* **Common:** Hypercalcemia, constipation, nausea, vomiting, abdominal pain.
* **Serious:** Metastatic calcification (vascular or soft tissue), metabolic alkalosis.
## Key Drug Interactions
* **Fluoroquinolones/Tetracyclines:** Calcium significantly decreases absorption. Separate administration by at least 2 hours before or 6 hours after calcium acetate.
* **Levothyroxine:** Oral calcium reduces levothyroxine absorption. Separate doses by at least 4 hours.
* **Bisphosphonates:** Calcium reduces absorption; separate doses by at least 2 hours.
* **Vitamin D:** Increased risk of hypercalcemia when used concomitantly.
## Monitoring
* **Serum Calcium:** Monitor weekly initially, then monthly.
* **Serum Phosphate:** Monitor weekly initially, then monthly.
* **Calcium-Phosphate Product:** Aim to keep the product below 55 mg²/dL² to minimize the risk of vascular calcification.
## Clinical Pearls
* **Timing:** Must be taken with meals to maximize efficacy as a phosphate binder.
* **Hypercalcemia Risk:** Calcium acetate exerts a potent effect on serum calcium levels; patients should be advised to avoid calcium-containing supplements or antacids while taking this medication.
* **Efficacy:** Generally considered more effective and more potent as a phosphate binder than calcium carbonate/citrate due to its higher solubility in the gastrointestinal tract.
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**Educational Disclaimer:** This information is intended for educational purposes only. Always verify current prescribing information, institutional protocols, and patient-specific factors via reliable clinical databases (e.g., Lexicomp, Micromedex) or medical literature before prescribing or administering medication.
