What is the recommended dosage and management of Velphoro (sucroferric oxyhydroxide) for patients with chronic kidney disease (CKD) and hyperphosphatemia?

Velphoro (Sucroferric Oxyhydroxide) Dosing and Management

Recommended Starting Dose

For adults and pediatric patients 12 years and older, start Velphoro at 500 mg (one tablet) three times daily with meals; for pediatric patients 9 to <12 years, start at 500 mg twice daily with meals. 1

Dose Titration Strategy

• Titrate by increments or decrements of one 500 mg tablet per day as frequently as weekly until serum phosphorus reaches acceptable levels, then continue regular monitoring 1
• If the daily dose cannot be divided equally among meals, administer the larger dose with the largest meal of the day 1
• Most adult patients and those ≥12 years require 1,500-2,000 mg daily (3-4 tablets) to achieve phosphorus control; pediatric patients 9 to <12 years typically need 1,500 mg daily (3 tablets) 1
• Maximum studied dose is 3,000 mg per day in adults and pediatric patients ≥9 years 1

Administration Requirements

• Tablets must be chewed or crushed—never swallow whole 1
• Must be taken with meals to maximize phosphate binding 1
• If doses are missed, resume with the next food intake 1

Clinical Context: When to Use Velphoro

Velphoro is indicated specifically for hyperphosphatemia in CKD patients on dialysis, not for pre-dialysis CKD patients with normal phosphorus levels 1. This aligns with KDIGO 2017 guidelines that recommend focusing phosphate-lowering treatment on patients with progressively or persistently elevated phosphate levels rather than attempting to maintain normal levels in all CKD patients 2.

Key Guideline Framework:

• In CKD G3a-G5D, lower elevated phosphate toward the normal range (Grade 2C recommendation) 2
• Treatment decisions should be based on serial assessments of phosphate, calcium, and PTH considered together, not single values 2
• Avoid calcium-based phosphate binders in patients with hypercalcemia 2, 3

Efficacy Expectations

• Velphoro achieves approximately 20% reduction in serum phosphate at 3 months across dialysis and advanced CKD populations 4
• Phosphate control is maintained long-term (up to 52 weeks) with mean serum phosphorus remaining within KDOQI target range (1.13-1.78 mmol/L) 5
• Velphoro offers significantly lower pill burden (mean 4.0 tablets/day) compared to sevelamer carbonate (10.1 tablets/day), with better adherence (86.2% vs 76.9%) 6, 5

Safety Monitoring

Common Adverse Effects:

• Discolored feces (12%) and diarrhea (6%) are the most common side effects 1, 6
• Gastrointestinal effects are typically mild, transient, and occur early in treatment, decreasing over time 6, 5
• Approximately 14% discontinue due to GI adverse effects, primarily diarrhea 4

Iron Monitoring Considerations:

Each 500 mg tablet contains 500 mg elemental iron (equivalent to 2,500 mg sucroferric oxyhydroxide) 1. However, iron absorption is minimal (<1%) with the majority of absorbed iron incorporated into red blood cells 7.

Monitor iron homeostasis in high-risk patients including those with: 1

• Peritonitis during peritoneal dialysis
• Significant gastric or hepatic disorders
• Recent major GI surgery
• History of hemochromatosis or iron accumulation disorders

Long-term Iron Safety:

• Mean serum ferritin may increase modestly, but transferrin saturation, serum iron, and hemoglobin remain generally stable 5
• Long-term studies (up to 2 years) show no evidence of iron accumulation or toxicity 5, 7

Drug Interactions

Velphoro can be administered concomitantly with most common CKD medications including calcitriol, ciprofloxacin, digoxin, enalapril, furosemide, statins, and warfarin 1

Timing Separations Required:

• Take acetylsalicylic acid, cephalexin, and doxycycline at least 1 hour before Velphoro 1
• Take levothyroxine at least 4 hours before Velphoro 1
• For other oral medications where reduced bioavailability would be clinically significant, consider separating administration timing and monitoring clinical responses 1

Clinical Pitfalls to Avoid

• Do not use phosphate binders in CKD G3b-G4 patients with normal phosphate levels, as this may increase coronary calcification without benefit 2
• Avoid hypercalcemia (Grade 2C recommendation) by limiting calcium-based binders when using Velphoro 2
• Do not base treatment decisions on single laboratory values—use trends of serial phosphate, calcium, and PTH measurements together 2
• For dialysis patients (CKD G5D), use dialysate calcium concentration between 1.25-1.50 mmol/L (2.5-3.0 mEq/L) to avoid hypercalcemia 2