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# Calcium Acetate
## Overview
Calcium acetate is a phosphate binder used to reduce serum phosphate levels in patients with hyperphosphatemia, primarily those with chronic kidney disease (CKD). It works by binding to dietary phosphate in the gastrointestinal tract, forming an insoluble calcium phosphate precipitate that is then excreted.
## Primary Indications
* **Hyperphosphatemia in patients with end-stage renal disease (ESRD):** To control serum phosphorus levels.
## Adult Dosing
* **Dosing:** Dosing is individualized based on serum phosphorus levels and dietary phosphate intake.
* **Starting Dose:** Typically 2 tablets (668 mg elemental calcium) taken with meals.
* **Titration:** Tablets should be increased or decreased gradually, usually in increments of 1-2 tablets per meal, to achieve target serum phosphorus levels.
* **Maximum Dose:** Generally, up to 12 tablets per day, divided among meals. It is crucial to avoid exceeding the recommended calcium intake.
## Pediatric Dosing
* Established pediatric dosing is not readily available. Use should be based on clinical judgment and often involves smaller, individualized doses with careful monitoring. Consult specialized pediatric resources.
## Dose Adjustments
* **Renal Impairment:** While used in CKD, caution is advised regarding calcium and phosphate balance. Dose is adjusted based on serum phosphorus.
* **Hepatic Impairment:** No specific adjustments generally needed.
## Contraindications
* Hypercalcemia.
* Hypersensitivity to calcium acetate.
* Conditions leading to hypercalcemia (e.g., certain malignancies, excessive vitamin D intake, sarcoidosis).
## Adverse Effects
* **Most Common:** Hypercalcemia (symptoms include constipation, nausea, vomiting, abdominal pain, dry mouth, thirst, polyuria, confusion).
* **Other:** Hypophosphatemia, gastrointestinal upset (nausea, vomiting, constipation, diarrhea).
## Key Drug Interactions
* **Tetracyclines and Fluoroquinolones:** Calcium acetate can decrease the absorption of these antibiotics; administer them at least 2 hours before or 6 hours after calcium acetate.
* **Thyroid Hormones (Levothyroxine):** Calcium can impair absorption; separate administration by at least 4 hours.
* **Bisphosphonates:** Concurrent use may reduce bisphosphonate absorption. Separate administration by at least 2 hours.
* **Calcium Channel Blockers:** High doses of calcium may potentiate effects.
* **Vitamin D and its analogs:** Increased risk of hypercalcemia.
## Monitoring
* **Serum Phosphorus:** Regularly monitor serum phosphorus levels, especially during initiation and titration.
* **Serum Calcium:** Regularly monitor serum calcium levels to detect and prevent hypercalcemia.
* **Electrolytes:** Monitor other electrolytes as clinically indicated.
* **Alkaline Phosphatase:** May be monitored in patients with CKD.
## Clinical Pearls
* Calcium acetate must be taken with meals to effectively bind dietary phosphate.
* The dose should be titrated to achieve a target serum phosphorus level, typically less than 6 mg/dL for patients with ESRD, but this target may vary based on institutional guidelines.
* Be vigilant for signs and symptoms of hypercalcemia, especially in patients taking other calcium-containing supplements or vitamin D.
* Consider the total elemental calcium content and the potential for hypercalcemia when prescribing. Each 668 mg tablet of calcium acetate contains approximately 169 mg of elemental calcium.
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*Disclaimer: This information is intended for clinical use and is not a substitute for professional medical advice. Always consult the most current prescribing information and relevant literature before making treatment decisions.*
