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# Calcium Acetate
## Overview
Calcium acetate is a phosphate binder used primarily in patients with end-stage renal disease (ESRD). It is more effective than calcium carbonate at binding dietary phosphate per gram of elemental calcium due to its higher solubility, requiring lower total elemental calcium intake to achieve equivalent phosphate binding.
## Primary Indications
Hyperphosphatemia in patients with end-stage renal disease (ESRD) secondary to chronic kidney disease.
## Adult Dosing
Initiate as 1,334 mg (2 capsules or 1 tablet) orally with each meal. Titrate based on serum phosphate levels. Maximum dose typically does not exceed 3,000 mg to 4,000 mg of elemental calcium per day (calcium acetate is ~25% elemental calcium). Individualize dosing according to local renal clinic protocols.
## Pediatric Dosing
Safety and efficacy have not been established in the pediatric population. Use is considered off-label and requires nephrology consultation. Dosing is typically titrated based on dietary phosphate intake and serum phosphate targets, often starting at 500–1,000 mg per meal.
## Dose Adjustments
* **Renal Impairment:** Required; dose must be titrated to maintain serum phosphorus within the target range (typically <5.5 mg/dL) while avoiding hypercalcemia.
* **Hypercalcemia:** If corrected serum calcium exceeds 10.5–11.0 mg/dL, discontinue or reduce dose.
## Contraindications
* Hypercalcemia.
* Hypophosphatemia.
* Severe constipation or bowel obstruction.
## Adverse Effects
* **Common:** Hypercalcemia, nausea, vomiting, constipation, dry mouth.
* **Serious:** Metastatic calcification (if calcium-phosphate product >55 mg²/dL²), severe hypercalcemia-induced arrhythmias.
## Key Drug Interactions
* **Quinolones and Tetracyclines:** Calcium significantly decreases absorption. Administer 2 hours before or 6 hours after calcium acetate.
* **Levothyroxine:** Calcium binds levothyroxine; space administration by at least 4 hours.
* **Bisphosphonates:** Separate by at least 2 hours to prevent reduced absorption.
* **Iron salts:** Reduce absorption; separate administration times.
## Monitoring
* **Serum Phosphorus:** Monitor at least monthly during titration.
* **Serum Calcium:** Monitor weekly during initiation and monthly thereafter.
* **Calcium-Phosphorus Product:** Keep <55 mg²/dL² to minimize the risk of vascular calcification.
## Clinical Pearls
* **Administration:** Must be taken with meals to facilitate effective binding of dietary phosphorus.
* **Elemental Content:** 667 mg of calcium acetate provides approximately 169 mg (4.25 mEq) of elemental calcium.
* **Risk:** Always evaluate the total daily calcium burden from all sources, including dialysate, to prevent hypercalcemia/calcific uremic arteriolopathy.
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**Educational Disclaimer:** This information is for educational purposes only. Clinical practice guidelines vary by institution; always verify current prescribing information, institutional protocols, and patient-specific factors with a senior clinician or pharmacist before administration.
