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# Calcium Acetate
## Overview
Calcium acetate is a phosphate binder used primarily in patients with end-stage renal disease (ESRD). It provides a high calcium content (approx. 25% elemental calcium by weight) and superior phosphate-binding capacity compared to calcium carbonate, particularly due to its increased solubility in near-neutral pH.
## Primary Indications
* Reduction of serum phosphorus in patients with end-stage renal disease (ESRD).
## Adult Dosing
* **Initial Dose:** 1,334 mg (2 capsules or 1 tablet) orally with each meal.
* **Titration:** Dosage should be titrated based on serum phosphate levels to target appropriate ranges per KDOQI/KDIGO guidelines.
* **Maximum Dose:** Generally titration continues until serum phosphorus is controlled; doses exceeding 10-12 grams daily increase the risk of hypercalcemia.
## Pediatric Dosing
* **Established Dosing:** Use is off-label in pediatrics. Dosing is highly variable and usually initiated at 40–80 mg/kg/day of elemental calcium, divided with meals.
* **Note:** Consult local pediatric institutional protocols or a pediatric nephrology specialist before initiation.
## Dose Adjustments
* **Renal Impairment:** No dose adjustment required for renal insufficiency, as this is the target population.
* **Hypercalcemia:** If serum calcium levels rise consistently above target, reduce dosage or switch to a non-calcium-based phosphate binder (e.g., sevelamer or lanthanum).
## Contraindications
* Hypercalcemia.
* Hypophosphatemia.
* Hypersensitivity to calcium acetate.
## Adverse Effects
* **Common:** Hypercalcemia, nausea, vomiting, constipation, abdominal pain.
* **Serious:** Metastatic calcification (vascular or soft tissue calcification associated with high calcium-phosphorus product >55 mg²/dL²).
## Key Drug Interactions
* **Fluoroquinolones/Tetracyclines:** Calcium significantly decreases absorption. Separate administration by at least 2 hours before or 6 hours after calcium acetate.
* **Levothyroxine:** Reduces absorption. Separate by at least 4 hours.
* **Bisphosphonates:** Reduces absorption. Space doses by at least 2 hours.
## Monitoring
* **Serum Phosphorus:** Monthly during titration, then periodically.
* **Serum Calcium:** Monitor weekly during initiation and dose titration; monitor monthly thereafter.
* **Calcium-Phosphorus Product:** Monitor to ensure product remains <55 mg²/dL² to minimize cardiovascular calcification risk.
## Clinical Pearls
* **Timing:** Must be administered immediately before or with meals to effectively bind dietary phosphorus.
* **Elemental Calcium:** 1,334 mg of calcium acetate contains 338 mg of elemental calcium.
* **Comparison:** If patients develop hypercalcemia, prioritize non-calcium based binders (e.g., sevelamer, sucroferric oxyhydroxide) to avoid further increasing the systemic calcium load.
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*Disclaimer: This information is for educational purposes only. Clinical practice varies by institution. Always verify dosages, contraindications, and drug interactions with current, local institutional guidelines and official prescribing information (package insert) before prescribing or administering medication.*
