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# Calcium Acetate
## Overview
Calcium acetate is a phosphate binder used to control serum phosphorus levels in patients with end-stage renal disease (ESRD). It is highly efficient at binding dietary phosphate in the GI tract to form insoluble calcium phosphate, which is then excreted in feces.
## Primary Indications
Hyperphosphatemia in patients with end-stage renal disease.
## Adult Dosing
* **Initial Dose:** 1,334 mg (two 667 mg capsules/tablets) orally with each meal.
* **Titration:** Adjust based on serum phosphorus levels to maintain target range (typically 3.5–5.5 mg/dL).
* **Maximum Dose:** Generally titration continues until phosphorus control is achieved; doses up to 2,668 mg (four 667 mg capsules/tablets) per meal have been used. High doses increase the risk of hypercalcemia.
## Pediatric Dosing
Dosing in children is not standardized and generally follows institutional protocols. Often initiated at lower doses (e.g., 500–668 mg per meal) based on serum phosphorus and caloric intake. Consultation with a pediatric nephrologist is mandatory.
## Dose Adjustments
* **Renal Impairment:** Required for all patients on dialysis.
* **Hypercalcemia:** If serum calcium levels rise, decrease or temporarily discontinue the dose.
## Contraindications
* Hypercalcemia.
* Hypophosphatemia.
* Nephrolithiasis (calcium-containing stones).
## Adverse Effects
* **Gastrointestinal:** Nausea, constipation, diarrhea, vomiting.
* **Metabolic:** Hypercalcemia (manifested as confusion, lethargy, cardiac arrhythmias, or constipation).
* **Other:** Pruritus/rash.
## Key Drug Interactions
* **Fluoroquinolones/Tetracyclines:** Calcium significantly decreases absorption. Separate administration by at least 2 hours.
* **Levothyroxine:** Separate by at least 4 hours.
* **Bisphosphonates:** Reduces oral bioavailability. Separate by at least 2 hours.
* **Iron Supplements:** Concurrent intake decreases iron absorption.
## Monitoring
* **Serum Phosphorus:** Every 2–4 weeks during titration, then periodically.
* **Serum Calcium:** Monitor frequently during dose initiation and titration to prevent hypercalcemia.
* **Calcium-Phosphorus Product:** Avoid exceeding 55 mg²/dL² to reduce the risk of metastatic calcification.
## Clinical Pearls
* **Timing:** Must be taken **with meals** to effectively bind dietary phosphate.
* **Efficacy:** Calcium acetate has a higher binding capacity per gram and is more soluble than calcium carbonate, potentially resulting in lower total calcium load for the same phosphate-binding effect.
* **Patient Education:** Advise patients to avoid taking other calcium supplements (e.g., antacids, vitamins) to avoid compounding hypercalcemia risk.
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**Educational Disclaimer:** This information is for educational purposes only. Clinical practice varies by institution and patient-specific factors. Always verify current prescribing information, institutional protocols, and pharmacokinetic data before administering or prescribing medication.
