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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 effective at binding dietary phosphate per milligram of elemental calcium than calcium carbonate and carries a lower risk of iatrogenic hypercalcemia when used appropriately.
## Primary Indications
* Reduction of serum phosphorus in patients with end-stage renal disease.
## Adult Dosing
* **Initial Dose:** 667 mg to 1,334 mg (1 to 2 tablets/capsicles) orally with each meal.
* **Titration:** Adjust based on serum phosphorus levels. Titrate upward every 2–3 weeks until serum phosphorus is within target range (typically <5.5 mg/dL).
* **Maximum Dose:** Generally 667 mg to 1,334 mg per meal; doses exceeding 10–12 tablets per day are rarely required and increase hypercalcemia risk.
## Pediatric Dosing
Safety and efficacy have not been established in pediatric patients. Use is off-label and centers on institution-specific protocols. Dosing is typically titrated based on dietary phosphate intake and phosphorus levels; consultation with a pediatric nephrologist is mandatory.
## Dose Adjustments
* **Hypercalcemia:** If serum calcium levels exceed 10.5 mg/dL, reduce dose or temporarily discontinue.
* **Renal Impairment:** Required for all patients on dialysis (primary population). Monitor calcium-phosphate product (goal <55 mg²/dL²).
## Contraindications
* Hypercalcemia.
* Hypophosphatemia.
* Known hypersensitivity to calcium acetate.
## Adverse Effects
* **Common:** Hypercalcemia, nausea, vomiting, constipation, abdominal pain.
* **Serious:** Calciphylaxis, metastatic calcification (associated with high calcium-phosphate product).
## Key Drug Interactions
* **Tetracyclines/Fluoroquinolones/Bisphosphonates:** Calcium acetate reduces absorption. Separate administration by at least 2–3 hours.
* **Levothyroxine:** Calcium salts decrease absorption; separate by at least 4 hours.
* **Iron Supplements:** Calcium reduces iron bioavailability; separate by 2 hours.
## Monitoring
* **Serum Phosphorus:** Monitor weekly during initiation/titration, then monthly.
* **Serum Calcium:** Monitor weekly during initiation/titration, then monthly.
* **Calcium-Phosphate Product:** Maintain <55 mg²/dL².
* **Signs of hypercalcemia:** Constipation, anorexia, nausea, mental status changes.
## Clinical Pearls
* Must be taken **with meals** to be effective as a phosphate binder. If a meal is missed, the dose should be skipped.
* Contains 169 mg (approx. 8.45 mEq) of elemental calcium per 667 mg tablet.
* Avoid concomitant use of vitamin D supplements or other calcium-based supplements unless directed by a nephrologist, as this significantly increases the risk of hypercalcemia.
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*Disclaimer: This information is for educational purposes only. Clinical protocols vary by institution. Always verify dosages, contraindications, and drug interactions using current, peer-reviewed clinical databases or the official FDA-approved prescribing information before administering any medication.*
