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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 works by binding to dietary phosphate in the gastrointestinal tract, reducing its absorption.
## Primary Indications
* Hyperphosphatemia in patients with end-stage renal disease (ESRD).
## Adult Dosing
* **Dosage depends on individual patient serum phosphate levels and dietary phosphate intake.** Dosing should be individualized.
* **Initial dose:** Typically 2 tablets (668 mg elemental calcium per 2 tablets) taken orally with each meal.
* **Titration:** Dosage can be increased by 1-2 tablets per meal as needed to control serum phosphate.
* **Maximum dose:** Generally not to exceed 16 tablets (about 4000 mg elemental calcium) per day. However, the total daily elemental calcium intake from all sources (including supplements, diet, and calcium-containing antacids) should not exceed 2 grams (2000 mg) to reduce the risk of hypercalcemia and extraskeletal calcification.
## Pediatric Dosing
* **Established pediatric dosing is not readily available.** Use in pediatric patients should be under the guidance of a pediatric nephrologist and based on individual assessment of serum phosphate levels and tolerance. The general principles of dose titration based on phosphate levels and monitoring for hypercalcemia apply.
## Dose Adjustments
* **Dose reduction or discontinuation:** Is necessary if serum calcium levels are elevated.
* **Dose adjustment:** May be needed based on individual serum phosphate and calcium levels.
## Contraindications
* Hypercalcemia.
* Hypersensitivity to calcium acetate.
* Patients with a history of calcium nephrolithiasis or hypercalciuria.
## Adverse Effects
* **Common:** Hypercalcemia (symptoms include constipation, nausea, vomiting, abdominal pain, dry mouth, polyuria, polydipsia, muscle weakness, bone pain, confusion, lethargy, cardiac arrhythmias).
* **Less common:** Gastrointestinal upset (nausea, vomiting, diarrhea), anorexia.
## Key Drug Interactions
* **Tetracyclines and fluoroquinolones:** Calcium acetate can chelate these antibiotics, reducing their absorption. Separate administration by at least 2 hours.
* **Digoxin:** Hypercalcemia increases the risk of cardiac arrhythmias with digoxin.
* **Bisphosphonates, sodium fluoride, phenytoin:** Calcium salts can decrease the absorption of these drugs. Separate administration by at least 2 hours.
* **Thiazide diuretics:** May increase the risk of hypercalcemia.
* **Vitamin D and its analogs:** Enhance calcium absorption and increase the risk of hypercalcemia.
## Monitoring
* **Serum calcium levels:** Regularly monitor serum calcium, especially at the start of therapy or with dose changes. Target ionized calcium levels should be maintained.
* **Serum phosphate levels:** Monitor as per clinical guidelines to assess efficacy.
* **Alkaline phosphatase:** May be monitored.
* **Signs and symptoms of hypercalcemia and extraskeletal calcification.**
## Clinical Pearls
* Calcium acetate should be taken with meals to maximize phosphate binding.
* The total daily intake of elemental calcium from all sources should be monitored closely to prevent hypercalcemia.
* Patients should be educated on the signs and symptoms of hypercalcemia.
* Consider alternative phosphate binders if hypercalcemia is persistent or difficult to manage.
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**Disclaimer:** This information is intended for healthcare professionals. Always consult the most current prescribing information and relevant clinical guidelines before making therapeutic decisions. Dosing recommendations may vary based on individual patient factors and local protocols.
