Maximum Sevelamer Dose Per Day
The maximum sevelamer dose is 13 grams per day (approximately 14-16 tablets of 800mg), though most patients achieve adequate phosphorus control with 6-8 grams per day. 1
Standard Dosing Approach
Initial dosing should start at 800 mg three times daily with meals (2.4 g/day total), taken 10-15 minutes before or during meals to maximize phosphate binding 1, 2
Dose titration should occur every 2 weeks based on serum phosphorus levels, gradually increasing until target phosphorus levels are achieved 3, 2
Average maintenance doses typically range from 3.4-7.1 g/day in clinical practice, with most patients stabilizing around this range 3, 2
Evidence for Maximum Dosing
In the Treat-to-Goal trial, 9 tablets of 800mg per day (7.2 g/day) given as 3 tablets three times daily with meals successfully achieved K/DOQI serum phosphorus targets in hemodialysis patients on monotherapy 4
Clinical studies have demonstrated safe use up to approximately 13 g/day when needed for refractory hyperphosphatemia, though doses above 8-10 g/day are less commonly required 1, 4
Target Phosphorus Levels
For dialysis patients (CKD Stage 5): target serum phosphorus is 3.5-5.5 mg/dL 5, 1
For non-dialysis CKD patients (Stages 3-4): target is 2.7-4.6 mg/dL 5, 1
Important Clinical Considerations
Gastrointestinal tolerability is the primary limiting factor for dose escalation, with approximately 38% of patients experiencing GI side effects (mainly nausea, vomiting, constipation) that may require dose reduction or discontinuation 3
Combination therapy with calcium-based binders is recommended by the National Kidney Foundation when hyperphosphatemia persists despite sevelamer monotherapy, while ensuring total elemental calcium intake does not exceed 2,000 mg/day 5, 1
Tablet burden can be substantial at higher doses; the 800mg tablet formulation reduces pill burden compared to smaller tablet sizes 4
Common Pitfall to Avoid
The most frequent error is inadequate dose titration—many clinicians stop at initial doses of 2.4-4.8 g/day when patients often require 6-8 g/day or higher to achieve phosphorus control. Gradual titration every 2 weeks until target phosphorus levels are reached is essential, as demonstrated in the Chinese hemodialysis study where average doses reached 7.1 g/day 2.