Dosing Recommendations for Sevelamer and Lanthanum in Hyperphosphatemia Management
Sevelamer Dosing
Start sevelamer at 800 mg three times daily with meals (or 1600-3200 mg total daily dose divided with meals), then titrate by one tablet per meal every 2 weeks based on serum phosphorus response, targeting phosphorus levels of 3.5-5.5 mg/dL. 1
Initial Dosing
- Starting dose: One to two 800 mg tablets OR two to four 400 mg tablets three times daily with meals 1
- Total daily starting dose range: 2400-4800 mg divided across three meals 1
Titration Strategy
- Adjust by one tablet per meal at two-week intervals to achieve target serum phosphorus of 3.5-5.5 mg/dL 1
- Monitor serum phosphorus levels regularly to guide dose adjustments 1
Typical Maintenance Doses
- Average daily dose in clinical trials: 4.9-6.5 g/day (range 0.8-13 g/day) 1
- In hemodialysis patients completing 52 weeks: average 6.5 g/day 1
- In peritoneal dialysis patients: average 5.9 g/day 1
Administration Instructions
- Must be taken with meals for optimal phosphate binding efficacy 1
- Tablets should be swallowed whole; do not crush or chew 1
- Separate dosing from other medications that may interact (ciprofloxacin, mycophenolate) 1
Lanthanum Dosing
Start lanthanum carbonate at 500-1000 mg three times daily with meals, then titrate every 2-3 weeks based on serum phosphorus response, with typical maintenance doses ranging from 1500-3000 mg daily. 2, 3
Initial Dosing
- Starting dose: 500-1000 mg three times daily with meals 3
- Total daily starting dose: 1500-3000 mg divided with meals 3
Titration Strategy
- Adjust dose every 2-3 weeks based on serum phosphorus levels 2
- Target serum phosphorus: 3.5-5.5 mg/dL (same as sevelamer) 2
Typical Maintenance Doses
- Effective dose range: 1500-3000 mg daily in divided doses 3
- Single-dose studies show 1000 mg lanthanum binds approximately 135 mg of dietary phosphate 4
Administration Instructions
- Take with or immediately after meals to maximize phosphate binding 2
- Tablets should be chewed completely before swallowing for optimal absorption 2
Comparative Dosing Considerations
Pill Burden
- Lanthanum requires significantly fewer tablets: average 4 tablets daily versus 7 tablets daily for sevelamer 5
- This reduced pill burden may improve adherence in patients struggling with polypharmacy 2
Phosphate Binding Efficiency
- Per tablet comparison: 1000 mg lanthanum binds ~135 mg phosphate versus 2400 mg sevelamer binding ~63 mg phosphate 4
- Lanthanum demonstrates 45% reduction in phosphate absorption versus 21% for sevelamer in single-dose studies 4
- Clinical efficacy studies show lanthanum reduced serum phosphate by 54% versus 38% for sevelamer over 6 months 3
Clinical Decision Algorithm
When to Use Sevelamer
- Preferred in patients with hypercalcemia or elevated calcium-phosphorus product (avoids calcium load) 2
- Consider in patients requiring LDL cholesterol reduction (34% decrease observed) 2
- May reduce mortality in incident dialysis patients based on trial data 2
- Attenuates progression of arterial calcifications compared to calcium-based binders 2
When to Use Lanthanum
- Preferred when pill burden is a major adherence concern (fewer tablets required) 5
- Consider when more potent phosphate binding per tablet is needed 4
- May induce less adynamic bone disease than calcium carbonate 2
- Use with caution: long-term safety data regarding lanthanum accumulation in liver, kidney, and bone remain limited, particularly in children 2
Important Monitoring Parameters
For Both Agents
- Serum phosphorus: Check every 2-4 weeks during titration, then monthly once stable 2, 1
- Serum calcium: Monitor for hypocalcemia (especially with concurrent calcimimetics) 2
- Intact PTH levels: Assess every 3 months 2
Sevelamer-Specific Monitoring
- Metabolic acidosis risk: Monitor serum bicarbonate (sevelamer hydrochloride can worsen acidosis) 2
- Consider sevelamer carbonate formulation if acidosis develops 2
Lanthanum-Specific Monitoring
- Gastrointestinal tolerability: Higher incidence of nausea (RR 2.99) and constipation (RR 2.98) versus placebo 6
- Long-term monitoring of liver and renal function due to tissue accumulation concerns 2
Critical Pitfalls to Avoid
Timing Errors
- Never administer phosphate binders between meals - they must be taken with food to bind dietary phosphate effectively 1
- Failure to time with meals results in ineffective phosphate control 7
Excessive Calcium Exposure
- Restrict calcium-based binder doses when using sevelamer or lanthanum to avoid positive calcium balance 2
- Excess calcium exposure increases vascular calcification risk across all CKD stages 2
Unrealistic Expectations
- Phosphate binder therapy introduces major pill burden that seriously compromises adherence 2
- In some patients, achieving normal phosphorus may not be possible or may unacceptably decrease quality of life 2
- Consider intensified dialysis protocols as alternative when phosphate control remains inadequate despite maximal medical therapy 2
Drug Interactions
- Separate sevelamer from ciprofloxacin and mycophenolate by several hours due to binding interactions 1
- Sevelamer does not affect digoxin, enalapril, iron, metoprolol, or warfarin pharmacokinetics 1
Special Population Considerations
Patients Not on Dialysis (CKD G3-G4)
- Only initiate phosphate binders for progressive or persistent hyperphosphatemia - not for prevention in normophosphatemic patients 2
- Evidence shows potential harm from phosphate binders in normophosphatemic CKD patients 2