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# Calcium Acetate
## Overview
Calcium acetate is a phosphate binder used to control hyperphosphatemia in patients with chronic kidney disease (CKD). It binds to dietary phosphate in the gastrointestinal tract, forming insoluble calcium phosphate, which is then excreted.
## Primary Indications
* Treatment of hyperphosphatemia in patients with end-stage renal disease (ESRD).
## Adult Dosing
* **Starting Dose:** 2 tablets (668 mg elemental calcium) orally with meals.
* **Titration:** Titrate dose to lower serum phosphate levels to target range (typically < 5.5 mg/dL). Doses can be increased by 1-2 tablets per meal as needed.
* **Maximum Dose:** Generally, not to exceed 12 tablets (4008 mg elemental calcium) per day. Some sources suggest a maximum of 1500 mg elemental calcium per meal, which approximates 12 tablets.
## Pediatric Dosing
* Dosing in pediatric patients is not well-established and should be individualized by a physician, often guided by serum phosphate levels. Consensus guidelines suggest starting doses:
* **1 to 11 years:** 2 tablets (668 mg elemental calcium) orally per day, divided into meals.
* **12 years and older:** 4 tablets (1336 mg elemental calcium) orally per day, divided into meals.
* Titration based on serum phosphate levels is crucial.
## Dose Adjustments
* **Renal Impairment:** Dose should be carefully adjusted based on serum calcium and phosphate levels. Patients with CKD are at increased risk of hypercalcemia.
* **Hypercalcemia:** If hypercalcemia occurs, reduce the dose or discontinue.
## Contraindications
* Hypercalcemia.
* Hypersensitivity to calcium acetate.
## Adverse Effects
* **Most Common:** Hypercalcemia (symptoms include constipation, nausea, vomiting, abdominal pain, dry mouth, thirst, increased urination, fatigue, weakness, headache, metallic taste).
* **Other:** Hypophosphatemia, GI upset.
## Key Drug Interactions
* **Tetracyclines and Fluoroquinolones:** Calcium acetate can decrease the absorption of these antibiotics. Administer these drugs at least 2 hours before or 3 hours after calcium acetate.
* **Thyroid Hormones:** Calcium acetate can decrease the absorption of levothyroxine. Separate administration by at least 4 hours.
* **Digitalis Glycosides:** Hypercalcemia can increase the risk of cardiac arrhythmias in patients taking digitalis.
* **Calcium Channel Blockers:** May increase risk of hypercalcemia and its sequelae.
* **Phosphate-depleting agents (e.g., sevelamer):** Monitor serum calcium and phosphate closely if used concurrently.
## Monitoring
* **Serum Calcium:** Regularly monitor serum calcium levels, especially during initial therapy and dose adjustments. Goal is to maintain serum calcium within the therapeutic range (typically < 10.5 mg/dL, but consider ionized calcium).
* **Serum Phosphate:** Monitor serum phosphate levels to ensure efficacy and titration.
* **Serum Magnesium and Alkaline Phosphatase:** May be monitored periodically in patients with ESRD.
## Clinical Pearls
* Calcium acetate should be taken concurrently with meals to effectively bind dietary phosphate.
* It is important to monitor for signs and symptoms of hypercalcemia, especially in patients with impaired renal function.
* Education regarding dietary phosphate restriction is an essential part of management.
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*Disclaimer: This information is intended for healthcare professionals and is not a substitute for professional medical advice. Always consult the most current prescribing information and relevant guidelines for definitive guidance. Dosing may vary based on individual patient factors, local protocols, and institutional formularies.*
