From the Guidelines
Ferric citrate (Auryxia) is a suitable alternative to Renvela (sevelamer) for administration via a Percutaneous Endoscopic Gastrostomy (PEG) tube, as it can be crushed and suspended in water, making it a viable option for patients requiring phosphate binding therapy. Several phosphate binders can be administered via PEG tubes as alternatives to Renvela, which tends to gel and clog tubes.
- Calcium-based binders like calcium acetate (PhosLo) and calcium carbonate can be crushed and dissolved for PEG administration, as noted in the K/DOQI clinical practice guidelines for bone metabolism and disease in chronic kidney disease 1.
- Lanthanum carbonate (Fosrenol) is available as a chewable tablet that can be crushed and mixed with water for tube administration.
- Aluminum-based binders like aluminum hydroxide can be used short-term and are available in liquid form, making them ideal for tube administration, although their use should be reserved for patients with serum phosphorus greater than 7.0 mg/dL and only for short-term therapy, as recommended by the K/DOQI guidelines 1.
- Sucroferric oxyhydroxide (Velphoro) can be crushed and mixed with water. When administering these medications through a PEG tube, it's essential to crush tablets thoroughly, mix with sufficient water to create a fine suspension, flush the tube before and after administration, and separate phosphate binder administration from other medications by at least one hour to prevent drug interactions and ensure optimal efficacy. 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 K/DOQI guidelines 1.
From the Research
Alternative Phosphate Binders to Renvela
Alternative phosphate binders to Renvela (sevelamer) that can be administered via a Percutaneous Endoscopic Gastrostomy (PEG) tube include:
- Lanthanum carbonate: a non-calcium-based phosphate binder that has been shown to be effective in lowering serum phosphate levels in patients with chronic kidney disease (CKD) 2, 3
- Calcium acetate or carbonate: calcium-based phosphate binders that can be used as an alternative to sevelamer, but may have a higher risk of hypercalcemia 4, 5
- Magnesium carbonate: a phosphate binder that has been shown to have a high phosphate-binding capacity and may be a suitable alternative to sevelamer 4
Administration via PEG Tube
When administering phosphate binders via a PEG tube, it is essential to consider the formulation and dosage of the medication. Lanthanum carbonate, for example, is available in chewable tablets or powder form, which can be easily administered through a PEG tube 3. Calcium acetate or carbonate and magnesium carbonate may also be available in formulations suitable for administration via a PEG tube.
Efficacy and Safety
The efficacy and safety of alternative phosphate binders should be carefully evaluated, taking into account the individual patient's needs and medical history. Lanthanum carbonate, for example, has been shown to have a lower risk of hypercalcemia and may be a suitable alternative to sevelamer in patients at risk of metabolic acidosis 2, 3. However, the use of lanthanum carbonate may be associated with gastrointestinal side effects, such as nausea and alkaline gastric reflux 3.