From the Guidelines
Sevelamer (Renagel, Renvela) is the preferred phosphate binder that does not significantly change the taste, with a typical starting dose of 800-1600 mg three times daily with meals. This recommendation is based on the most recent and highest quality evidence available, which suggests that sevelamer is effective in controlling serum phosphorus levels without significant gastrointestinal side effects or alteration in taste 1.
Key Considerations
- Sevelamer works by binding to dietary phosphate in the gut, preventing its absorption into the bloodstream, which is crucial for patients with kidney disease who cannot adequately excrete phosphate.
- Taking sevelamer in the middle of meals rather than before can help minimize any potential taste issues, and ensuring pills are swallowed quickly without chewing will prevent any medicinal taste.
- Regular monitoring of phosphorus levels is necessary to adjust dosing appropriately, as some patients may require different phosphate binders to find the one that works best for their specific situation regarding efficacy and palatability.
- The choice of phosphate binder should be determined by patient preference, compliance, comorbid illnesses, side effects, cost, and the ability to control serum phosphorus levels while maintaining the desired calcium-phosphorus product, as recommended by the Work Group 1.
Comparison with Other Options
- Calcium acetate (PhosLo) is another phosphate binder with minimal impact on taste, but sevelamer is preferred due to its efficacy and lower risk of gastrointestinal side effects 1.
- Aluminum hydroxide should be reserved for patients with serum phosphorus greater than 7.0 mg/dL and only for short-term therapy due to the potential for neurotoxicity and osteomalacia associated with long-term aluminum intake 1.
From the Research
Phosphate Binders and Taste
- Phosphate binders are used to treat hyperphosphatemia in patients with chronic kidney disease, and some may have a metallic or unpleasant taste 2, 3.
- Sevelamer carbonate is a phosphate binder that is available in a powder formulation, which can be mixed with water to reduce the risk of unpleasant taste 2, 3.
- Studies have shown that sevelamer carbonate has a similar efficacy to other phosphate binders, such as lanthanum carbonate, in reducing serum phosphate levels 4.
- Sevelamer carbonate has been reported to have fewer side effects from the gastrointestinal tract compared to sevelamer hydrochloride tablets 3.
Comparison of Phosphate Binders
- Different phosphate binders have varying phosphate-binding capacities, with sevelamer hydrochloride or carbonate having a relative phosphate-binding coefficient (RPBC) of 0.75 compared to calcium carbonate 5.
- Lanthanum carbonate has been shown to be more efficacious in lowering serum phosphate concentrations compared to sevelamer carbonate 4.
- Sevelamer reduces serum cholesterol levels and exerts anti-inflammatory effects, while bixalomer is associated with fewer gastrointestinal symptoms compared to sevelamer 6.