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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 potent gram-for-gram than calcium carbonate at binding dietary phosphorus without requiring an acidic gastric environment for dissolution.
## Primary Indications
* Reduction of serum phosphorus in patients with hyperphosphatemia associated with chronic kidney disease (CKD).
## Adult Dosing
* **Initial:** 1,334 mg (two 667 mg capsules/tablets) orally with each meal.
* **Titration:** Titrate to maintain serum phosphorus concentrations below 5.5 mg/dL. Usual range is 1,334 mg to 2,668 mg per meal.
* **Max:** Data varies by institution; safety profile limits generally reflect the avoidance of hypercalcemia (typically not exceeding 12-15 grams daily).
## Pediatric Dosing
* **Safety/Efficacy:** Well-established guidelines for pediatric dosing are limited.
* **General Approach:** Dosing is often extrapolated from adult data, typically starting at 334–667 mg with each meal, adjusted based on serum phosphorus and calcium levels.
* **Note:** Consult institutional pediatric nephrology protocols for specific weight-based titration.
## Dose Adjustments
* **Renal Impairment:** Used specifically in ESRD.
* **Hypercalcemia:** If hypercalcemia develops, reduce dose or discontinue therapy until calcium levels normalize.
## Contraindications
* Hypercalcemia.
* Hypersensitivity to calcium acetate or any product components.
## Adverse Effects
* **Common:** Hypercalcemia, nausea, vomiting, constipation, abdominal pain.
* **Serious:** Metastatic calcification (associated with high calcium-phosphate product), cardiac arrhythmias (secondary to hypercalcemia).
## Key Drug Interactions
* **Fluoroquinolones/Tetracyclines:** Calcium significantly decreases absorption. Separate administration by at least 2–3 hours.
* **Levothyroxine:** Calcium interferes with absorption. Separate by at least 4 hours.
* **Bisphosphonates:** Reduces oral bioavailability. Separate doses by at least 2 hours.
* **Iron Supplements:** Reduced absorption; separate by 2 hours.
## Monitoring
* **Serum Phosphorus:** Titrate dose to target levels per KDIGO guidelines.
* **Serum Calcium:** Monitor weekly during initiation/titration, then monthly/quarterly.
* **Calcium-Phosphate Product:** Risk of vascular calcification increases when the product (Ca × P) exceeds 55 mg²/dL².
## Clinical Pearls
* **Timing:** Must be taken with meals to effectively bind dietary phosphorus. Taking the dose *before* or *after* the meal significantly reduces efficacy.
* **Potency:** 667 mg of calcium acetate provides 169 mg (approx. 8.45 mEq) of elemental calcium.
* **Vascular Risk:** Patients should be monitored for signs of extraskeletal calcification, particularly if receiving concomitant Vitamin D therapy.
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**Educational Disclaimer:** This information is for educational purposes only and does not constitute medical advice. Clinical protocols vary by institution. Always verify dosages, contraindications, and drug interactions against the most current prescribing information and institutional pharmacy guidelines before administration.
