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# Calcium acetate
## Overview
Calcium acetate is a calcium salt used primarily as a phosphate binder. It provides 25% elemental calcium by weight (higher potency for phosphate binding than calcium carbonate).
## Primary Indications
Hyperphosphatemia in patients with end-stage renal disease (ESRD) on hemodialysis.
## Adult Dosing
* **Initial Dose:** 1,334 mg (2 capsules or 1 tablet) orally with each meal.
* **Titration:** Adjust dose based on serum phosphate levels. Most patients require 2–4 tablets/capsules per meal to achieve target phosphate levels.
* **Maximum Dose:** Generally considered 4–5 grams of elemental calcium per day from all sources to prevent hypercalcemia.
## Pediatric Dosing
Safety and efficacy have not been established in pediatric patients. Use is typically off-label and guided by pediatric nephrology protocols. Starting doses are often lower (e.g., 20–50 mg/kg/day divided with meals), titrated based on serum phosphate.
## Dose Adjustments
* **Renal Impairment:** Requires careful monitoring of serum calcium and phosphate to prevent hypercalcemia/soft tissue calcification.
* **Hepatic Impairment:** No formal adjustments, but monitor for calcium overload.
## Contraindications
* Hypercalcemia.
* Hypophosphatemia.
* Nephrolithiasis (calcium-containing stones).
## Adverse Effects
* **Common:** Hypercalcemia, nausea, constipation, vomiting.
* **Serious:** Metastatic calcification (vascular or soft tissue), severe hypercalcemia (confusion, arrhythmias, nephrocalcinosis).
## Key Drug Interactions
* **Fluoroquinolones/Tetracyclines:** Calcium significantly decreases absorption. Administer antibiotics 2 hours before or 6 hours after calcium acetate.
* **Levothyroxine:** Reduces absorption. Separate administration by at least 4 hours.
* **Bisphosphonates:** Reduces absorption. Separate by at least 2 hours.
* **Iron salts:** Reduces absorption. Space doses.
## Monitoring
* **Serum Calcium:** Monitor weekly during initiation and dose titration; then periodically.
* **Serum Phosphate:** Monitor periodically to ensure therapeutic range.
* **Calcium-Phosphate Product:** Maintain < 55 mg²/dL² to reduce risk of vascular calcification.
## Clinical Pearls
* **Administration:** Must be taken with meals to effectively bind dietary phosphate. If taken without food, it provides minimal phosphate-binding benefit.
* **Adherence:** High pill burden is a common compliance barrier.
* **Hypercalcemia:** Instruct patients to report symptoms of hypercalcemia (nausea, vomiting, confusion, constipation, weakness).
* **Avoid:** Vitamin D supplements or high-calcium vitamin intake concurrent with calcium acetate unless directed by a physician, due to the high risk of hypercalcemia.
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**Educational Disclaimer:** This information is for educational purposes only. Clinical practice guidelines and individual patient profiles vary. Always verify current prescribing information, institutional protocols, and pharmacokinetic data before administering or prescribing any medication.
