From the Guidelines
Alternatives to sevelamer for managing hyperphosphatemia include calcium-based phosphate binders, lanthanum carbonate, ferric citrate, and sucroferric oxyhydroxide, with the choice among these alternatives based on individual factors including calcium levels, iron status, medication cost, pill burden tolerance, and side effect profile. These medications work by binding to dietary phosphate in the gut, preventing its absorption 1. Calcium-based binders, such as calcium carbonate 500-1500 mg with meals or calcium acetate 667-1334 mg with meals, are often first-line due to lower cost but may increase calcium load, potentially contributing to vascular calcification in some patients 1. Lanthanum carbonate (500-1000 mg with meals) provides effective phosphate binding without calcium but may cause gastrointestinal side effects 1. Iron-based binders, such as ferric citrate (1-2 tablets with meals) and sucroferric oxyhydroxide (500 mg with meals), offer the additional benefit of improving iron parameters in patients with chronic kidney disease 1.
Some key considerations when choosing an alternative to sevelamer include:
- Calcium levels: Patients with high calcium levels may benefit from non-calcium based binders such as lanthanum carbonate or iron-based binders 1
- Iron status: Patients with iron deficiency may benefit from iron-based binders such as ferric citrate or sucroferric oxyhydroxide 1
- Medication cost: Calcium-based binders are often less expensive than other alternatives 1
- Pill burden tolerance: Patients with difficulty taking multiple pills may benefit from binders with fewer tablets or capsules 1
- Side effect profile: Patients with gastrointestinal side effects may benefit from binders with fewer gastrointestinal side effects such as calcium carbonate 1
Dosing should be adjusted based on serum phosphate levels, with medications taken with meals for optimal phosphate binding 1. The Work Group strongly recommends adding a non-calcium, nonmagnesium, nonaluminum phosphate binder to decrease the total calcium intake for patients on calcium-containing phosphate binders in amounts exceeding 2,000 mg total elemental calcium content 1.
From the Research
Alternatives to Sevelamer (Renvela)
The following alternatives to Sevelamer (Renvela) are available:
- Lanthanum carbonate: A study comparing the efficacy of lanthanum carbonate and sevelamer carbonate as phosphate binders in chronic kidney disease found that lanthanum carbonate was more efficacious in lowering serum phosphate concentrations 2.
- Calcium-based phosphate binders: A study comparing the efficacy and safety of sevelamer with calcium carbonate in the treatment of hyperphosphatemia in hemodialysis patients found that both sevelamer and calcium carbonate were effective in controlling hyperphosphatemia, but sevelamer did not result in an increase in the incidence of hypercalcemia seen with calcium carbonate 3.
- Iron-based binders: A systematic review and meta-analysis comparing the efficacy and safety of sevelamer and lanthanum with calcium-containing and iron-based binders in treating hyperphosphatemia in patients with chronic kidney disease found that sevelamer was similar to iron-based binders in three studies 4.
Key Findings
- Lanthanum carbonate may be a more effective alternative to sevelamer in lowering serum phosphate concentrations 2.
- Calcium-based phosphate binders may be associated with a higher risk of hypercalcemia compared to sevelamer 3.
- Sevelamer may be associated with a nonsignificant reduction in mortality and significantly lower hospitalization rates and hypercalcemia compared to calcium-based binders 4.