From the Guidelines
Treatment for hyperphosphatemia should focus on patients with progressive or persistent hyperphosphatemia, rather than those with normal phosphate levels. This approach is based on the latest evidence from the Kidney Disease: Improving Global Outcomes (KDIGO) 2017 clinical practice guideline update 1. The treatment involves:
- Dietary phosphate restriction: limiting intake of high-phosphate foods such as processed foods, dairy products, and certain beverages
- Phosphate binders: medications taken with meals to prevent phosphate absorption from the gut, including calcium-based options (calcium carbonate 500-1500 mg with meals, calcium acetate 667-1334 mg with meals) and non-calcium based options (sevelamer 800-1600 mg with meals, lanthanum carbonate 500-1000 mg with meals, and ferric citrate 1-2 tablets with meals)
- Addressing the underlying cause: optimizing dialysis for patients with kidney disease, and considering volume expansion with saline for acute severe hyperphosphatemia if kidney function is adequate Regular monitoring of serum phosphate levels is necessary to adjust treatment accordingly, as hyperphosphatemia contributes to cardiovascular calcification, secondary hyperparathyroidism, and bone disease, particularly in chronic kidney disease patients where phosphate excretion is impaired. It is also important to consider the phosphate source (e.g., animal, vegetable, additives) in making dietary recommendations 1.
From the FDA Drug Label
Sevelamer Hydrochloride versus Active-Control, Cross-Over Study in Hemodialysis Patients Eighty-four CKD patients on hemodialysis who were hyperphosphatemic (serum phosphorus >6. 0 mg/dL) following a two-week phosphate binder washout period were randomized in a cross-over design to receive in random order sevelamer hydrochloride and active control for eight weeks each. Patients started on treatment three times per day with meals Over each eight-week treatment period, at three separate time points the dose of sevelamer hydrochloride could be titrated up to control serum phosphorus, the dose of active control could also be altered to attain phosphorus control. Both treatments significantly decreased mean serum phosphorus by about 2 mg/dL (Table 6)
For high phos (hyperphosphatemia), the recommended treatment is sevelamer hydrochloride. The dose can be titrated up to control serum phosphorus, and it is recommended to be taken three times per day with meals. The average daily dose at the end of treatment was 4.9 g (range of 0.0 to 12.6 g) 2.
- Key points:
- Sevelamer hydrochloride decreases mean serum phosphorus by about 2 mg/dL
- Dose can be titrated up to control serum phosphorus
- Recommended to be taken three times per day with meals
- Average daily dose at the end of treatment was 4.9 g (range of 0.0 to 12.6 g) 2
From the Research
Treatment Options for Hyperphosphatemia
To manage high phosphate levels, several treatment options are available, including:
- Dietary restriction of phosphorus intake
- Phosphate binders to reduce intestinal phosphate absorption
- Dialysis to remove excess phosphate from the blood 3
- Vitamin D analogs to regulate parathyroid hormone and calcium levels 4, 5
Phosphate Binders
Phosphate binders are a crucial component of hyperphosphatemia treatment. The available options include:
- Calcium-based binders (e.g., calcium acetate, calcium carbonate) 4, 6
- Non-calcium-based binders (e.g., sevelamer, lanthanum carbonate, magnesium salts) 3, 6
- Iron-based binders (e.g., sucroferric oxyhydroxide) 7 Each type of phosphate binder has its own advantages and disadvantages, and the choice of binder should be individualized based on patient characteristics and clinical context 3, 6
Key Considerations
When selecting a phosphate binder, it is essential to consider the following factors: