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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 more efficient per milligram of elemental calcium than calcium carbonate at binding dietary phosphorus in the intestinal lumen because it is more soluble across a wider pH range.
## Primary Indications
* Reduction of serum phosphorus in patients with end-stage renal disease (ESRD) on hemodialysis or peritoneal dialysis.
## Adult Dosing
* **Initial Dose:** 1,334 mg (two 667 mg capsules/tablets) orally with each meal.
* **Titration:** Adjust based on serum phosphate levels to achieve target ranges (typically 3.5–5.5 mg/dL).
* **Maximum Dose:** No strict physiological maximum; however, current clinical practice generally limits doses to avoid hypercalcemia (typically < 3,000 mg elemental calcium per day from all sources).
* *Note: Dosing depends on institutional protocol and serum calcium/phosphate monitoring.*
## Pediatric Dosing
* **Safety/Efficacy:** Well-established dosing is not standard; use is generally off-label and guided by pediatric nephrology specialists.
* **Common Practice:** Start at 500–1,000 mg/day divided with meals, titrated based on serum phosphorus and calcium-phosphorus product. Use with caution due to the risk of hypercalcemia.
## Dose Adjustments
* **Hypercalcemia:** If hypercalcemia develops, reduce or discontinue the dose.
* **Renal Impairment:** Exclusively indicated for ESRD; no dose adjustment required for renal function itself, but mandatory adjustment for serum calcium levels.
## Contraindications
* Hypercalcemia.
* Hypophosphatemia (rare for this patient population).
## Adverse Effects
* **Common:** Hypercalcemia, constipation, nausea, vomiting.
* **Serious:** Metastatic calcification (vascular or soft tissue calcification) if calcium-phosphorus product exceeds 55 mg²/dL².
## Key Drug Interactions
* **Tetracyclines/Quinolones:** Calcium binds these drugs, significantly reducing their absorption. Administer 2 hours before or 6 hours after calcium acetate.
* **Thyroid Hormones:** Calcium acetate can decrease levothyroxine absorption. Separate administration by at least 4 hours.
* **Corticosteroids:** May reduce calcium absorption.
## Monitoring
* **Serum Phosphorus:** Monitor weekly during initial titration.
* **Serum Calcium:** Monitor weekly initially; hypercalcemia is a primary concern.
* **Calcium-Phosphorus Product:** Keep < 55 mg²/dL².
## Clinical Pearls
* **Administration:** Must be taken with meals to bind dietary phosphorus. If a meal is missed, the dose should be skipped.
* **Calcium Content:** 667 mg of calcium acetate provides approximately 169 mg (8.45 mEq) of elemental calcium.
* **Switching:** Avoid switching between calcium salts without recalculating elemental calcium content.
* **Vascular Calcification:** Long-term use in patients already receiving high doses of calcium-based binders or vitamin D analogs increases the risk of adynamic bone disease and vascular calcification.
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**Educational Disclaimer:** This information is for educational purposes only. Always verify dosing, contraindications, and drug interactions against current institutional protocols and the most recent manufacturer prescribing information (e.g., DailyMed or Lexicomp) before prescribing or administering medication.
