All rights reserved. Compare prices and find information about prescription drugs used to treat Hyperphosphatemia. Am J Kidney Dis. Diagnose and treat the cause: Eg, hyperphosphatemia due to tumor lysis responds to forced saline diuresis to enhance urinary losses 2. Hyperphosphatemia is when you have too much phosphate in your blood. Phosphate binders. Fluids and electrolytes. Common adverse effects from clinical trials include diarrhea, discolored feces (dark), constipation, nausea, and vomiting.14 This product has been studied in clinical trials up to 52 weeks.17. NICE clinical guideline 157 – hyperphosphataemia in chronic kidney disease 9 Strength of recommendations Some recommendations can be made with more certainty than others. The phosphate binder ferric citrate and mineral metabolism and inflammatory markers in maintenance dialysis patients: results from prespecified analyses of a randomized clinical trial. In patients with normal kidney function, the treatment should be focused on promoting phosphaturia with the administration of normal saline as well as acetazolamide and sodium bicarbonate if needed. Adverse effects and toxicity limited the use of these agents, and therapy evolved with calcium carbonate, calcium acetate, sevelamer, and lanthanum carbonate. National Kidney Foundation. Long-term effects of the iron-based phosphate binder, sucroferric oxyhydroxide, in dialysis patients. Recently, two iron-based phosphate binders have been approved. Sucroferric oxyhydroxide is an iron(III) oxyhydroxide molecule bound to a carbohydrate molecule, with iron constituting approximately 20% of the molecular weight. Cambridge, MA: Genzyme Corporation; 2011.24. Sevelamer is an insoluble polymer that is not absorbed from the gastrointestinal (GI) tract and is considered as effective as calcium acetate or calcium carbonate in phosphorus-lowering ability.10 Sevelamer has been shown to decrease cardiovascular mortality in CKD patients.11 It can decrease absorption of various medications such as vitamins D, E, K, folic acid, levothyroxine, mycophenolate, tacrolimus, and quinolone antibiotics. Velphoro (sucroferric oxyhydroxide) package insert. Calcium-based products are often started in stage 4 secondary to efficacy, safety, and cost. Renagel (sevelamer hydrochloride) package insert. Overall cost of this medication is low, so it is an attractive first-line agent if hypercalcemia is not a concern.8, Calcium Acetate: Approved in 1990, calcium acetate (PhosLo, various other brands) is considered a first-line therapy for lowering phosphate in CKD stage 4. Hyperphosphatemia is an electrolyte disorder in which there is an elevated level of phosphate in the blood. Normal levels of phosphorus are between 2.5 to 4.5mg/dL (0.81-1.45 mmol/L). 4 These guidelines recommend that for high phosphorus uncontrolled by dietary measures, calcium-based phosphate binders are a reasonable choice for CKD stages 3 and 4. Nephrol Dial Transplant. Sevelamer and lanthanum can be used in the setting of hypercalcemia, and they offer a cardiovascular mortality benefit. However, hyperphosphatemia may indirectly cause symptoms in two ways. Randomized, double-blind, placebo-controlled, dose-titration, phase III study assessing the efficacy and tolerability of lanthanum carbonate: a new phosphate binder for the treatment of hyperphosphatemia. The active form of the drug is insoluble and cannot be metabolized or absorbed. 2015;30(6):1037-1046.17. Sevelamer 800-1600mg TID, lanthanum carbonate 1500-4500mg daily, calcium acetate or calcium carbonate). 1. Control of Hyperphosphatemia among Patients with ESRD. Kidney Int. Sucroferric oxyhydroxide and ferric citrate are calcium-free and may offer benefits in those with a high pill burden and in patients with concurrent anemia, respectively. Oral phosphate binders in patients with kidney failure. dialysis treatment and the use of drugs that include phos- phate binders, active/analog vitamin D, and calcimimet- ics.3,11Renal replacement therapy with dialysis is needed to compensate for loss of kidney function in advanced Finally, the pharmacist is in a key position to help patients optimize therapy with an understanding of drug interactions, adverse effects, medication costs, and overall pill burden. Clinical Pharmacology [online database]. The first phosphate binders were aluminum- and magnesium-based antacids. Magnesium levels of patients on dialysis are typically higher than of those with normal renal function; use of magnesium salts may place a patient at risk for hypermagnesemia and respiratory arrest. Am J Kidney Dis. Sevelamer hydrochloride has the potential to reduce serum bicarbonate, which has led to some cases of metabolic acidosis in dialysis patients; this effect has not been reported in the carbonate form.11, Lanthanum Carbonate: Lanthanum carbonate (Fosrenol) is a trivalent cation rare-earth element that binds phosphate. What Role Does Low-Dose Aspirin Play in Long-Term Prostate Cancer Survival? A second dose reduction may be implemented if needed or clinically indicated for persistent hyperphosphatemia (>7 mg/dL) at every cycle; Restriction of phosphate intake to 600 – 800 mg/day. Floege J, Covic AC, Ketteler M, et al. the presence of hyperphosphatemia to prevent rise of phosphate concentration and as an early intervention for cardiovascular risk. Auryxia (ferric citrate) package insert. Package labeling indicates a starting dose of 2 tablets orally 3 times per day with meals, adjusting the dose by 1 to 2 tablets as needed to maintain serum phosphorus levels at target, with the maximum being 12 tablets daily. Causes of hyperphosphatemia include impaired phosphorus excretion (renal failure or hypoparathyroidism), redistribution of phosphorus to the extracellular fluid (acid-base imbalance, rhabdomyolysis, muscle necrosis, or tumor lysis during chemotherapy), and increased phosphate intake. For patients with CKD refractory hyperphosphatemia despite diet and binders, daily or prolonged dialysis, calcimimetics or parathyroidectomy may be necessary. Phosphate binders are indicated for all patients with CKD and eGFR <60mL/min/1.73m2 with hyperphosphatemia that does not respond to oral restrictions alone. 2010;362(14):1312-1324.3. In vitro hemolysis Treatment of hyperphosphatemia in hemodialysis patients: the Calcium Acetate Renagel Evaluation (CARE Study). Am J Kidney Dis. Sevelamer 800-1600mg TID, lanthanum carbonate 1500-4500mg daily, calcium acetate or calcium carbonate). Skip header and main navigation. The tablets should not be swallowed but can be chewed or crushed.15, The most common adverse effects of sucroferric oxyhydroxide in clinical trials were diarrhea, discolored feces (black), nausea, and abnormal taste.14-16 Sucroferric oxyhydroxide may affect absorption of some medications; alendronate and doxycycline should be separated by at least one hour and concurrent use of levothyroxine and vitamin D should be avoided entirely. Recent advancements have been made in phosphate-binder treatment. Sucroferric oxyhydroxide was found to be noninferior to sevelamer carbonate in reducing serum phosphate in an open-label clinical trial of 1,059 patients.14 The sugar portion is also absorbable, with one tablet producing 1.4 grams of carbohydrates, which may be of concern for the diabetic patient.15 The initial dose is 500 mg three times daily with meals and can be titrated at weekly intervals by 500 mg/day until serum phosphorus levels are 5.5 mg/dL. Chronic hyperphosphatemia, which occurs often in patients with chronic kidney disease, should be treated with low phosphate diet to a maximum dietary intake of 900mg/day (avoid dairy products, sodas, processed foods) and phosphate binders (e.g. Stage 5 patients may use either calcium or non-calcium-based binders, and if a dialysis patient remains hyperphosphatemic (>5.5 mg/dL) it is reasonable to use a combination of both.4. ... medical advice, diagnosis or treatment. Calcium-based phosphate binders are often used for CKD stages 3 to 5; they are inexpensive, but have a potential to cause hypercalcemia. 11 suppl 2 S107-S114. Phosphate binders such as aluminum-based antacids, magnesium-based antacids, calcium carbonate, calcium acetate, sevelamer, and lanthanum may be necessary for those patients whose phosphorus levels stay elevated despite dietary restrictions. 3rd ed. 2004;64(9):985-996.13. Coladonato JA. Common adverse effects include vomiting, nausea, diarrhea, and dyspepsia. This material is provided for educational purposes only and is not intended for medical advice, diagnosis or treatment. This iron-containing product is contraindicated in iron-overload syndromes such as hemochromatosis. Hyperbilirubinemia KDIGO 2017 Clinical Practice Guideline Update for the Diagnosis, Evaluation, Prevention, and Treatment of Chronic Kidney Disease–Mineral and Bone Disorder (CKD-MBD) KKISU_v7_i1_COVER.indd 1ISU_v7_i1_COVER.indd 1 331-05-2017 13:23:051-05-2017 13:23:05 Goldsmith D, Covic A. In this situation, sevelamer and lanthanum have demonstrated a cardiovascular mortality benefit. Hyperlipidemia. Hyperphosphatemia in the presence of hypercalcemia imposes a high risk of metastatic calcification Clinical Findings Symptoms are those of the underlying disorders (eg, CKD, hypoparathyroidism) 2013 May;73(7):673-88. Often there is also low calcium levels which can result in muscle spasms.. Serum phosphorus concentration is normally 2.7 to 4.5 mg/dL (0.87-1.45 mmol/L). Fifty percent of mortality in patients with CKD is related to cardiovascular complications, with the highest risk being in the presence of hyperphosphatemia, hypercalcemia, and hyperparathyroidism.3 In general, the goal is to achieve a phosphorus concentration of 2.7 to 4.6 mg/dL in patients not receiving dialysis. In chronic hypophosphatemia, standard treatment includes oral phosphate supplementation and active vitamin D. Future treatment for specific disorders associated with chronic hypophosphatemia may include cinacalcet, calcitonin, or dypyrimadole. Swainston Harrison T, Scott L. Lanthanum carbonate. CONTENTS Symptoms Phosphate level Causes of hyperphosphatemia Treatment Algorithm Podcast Questions & Discussions Pitfalls PDF of this chapter (or create customized PDF) Hyperphosphatemia itself is generally asymptomatic. Med Lett Drugs Ther. Kidney International. Drugs. Acute hyperphosphatemia is often a result of intracellular -> extracellular shift (tumor lysis syndrome, rhabdomyolisis, among other causes). Tumor lysis Most people have no symptoms while others develop calcium deposits in the soft tissue. Data sources include IBM Watson Micromedex (updated 7 Dec 2020), Cerner Multum™ (updated 4 Dec 2020), ASHP (updated 3 Dec … Lederer E. Hyperphosphatemia. Pharmacotherapy Principles and Practice. Calcium carbonate package insert. Progressive accumulation with continued use has been demonstrated in animals, and has been detected in human bone.12 Lanthanum is as effective as calcium carbonate, but with a much lower incidence of hypercalcemia. The Guideline Development Group makes a recommendation based on the trade-off between the benefits and harms of an intervention, taking into account the Kidney Int. www.clinicalpharmacology.com. Medscape. This guideline should be used to treat hyperphosphataemia and secondary hyperparathyroidism (SHPT) in patients with chronic kidney disease (CKD) (all stages including those requiring dialysis). It is important for the pharmacist, as an essential member of the healthcare team, to be familiar with these new treatments in order to optimize therapy in the setting of hyperphosphatemia. Copyright © 2000 - 2020 Jobson Medical Information LLC unless otherwise noted. Most patients are asymptomatic and the symptoms, when present, are usually related to other abnormalities that may be associated (in hypocalcemic patients: muscle cramps, tetany, numbness and tingling; in uremic patients, fatigue, shortness of breath, nausea, sleep disorders). N Engl J Med. Acute hemolysis Patients with acute hyperphosphatemia and bad kidney function may benefit from insulin and glucose or dialysis (peritoneal dialysis may be better in such cases). Calcium salts are associated with multiple drug interactions. Ferric citrate has the potential to decrease the absorption of doxycycline. Cambridge, MA: Genzyme Corporation; 2015.23. Foundation K/DOQI bone metabolism and disease guidelines recommend maintenance of serum phosphorus (P) below 5.5 mg/dL, and Ca × P product less than 55 mg2/dL2. Gold Standard, Inc. Sevelamer. Lexi-Drugs. 2006;48(1228):15-16.8. Based on these findings, To comment on this article, contact rdavidson@uspharmacist.com. This review describes conceptual models of phosphate toxicity, summarizes the evidence base for treatment and prevention of hyperphosphatemia, and identifies important knowledge gaps in the field. Magnesium hydroxide has similar phosphate-lowering capacity compared to calcium-based agents and is infrequently used as add-on therapy.2 The most common adverse effect experienced by patients taking magnesium-based phosphate binders is diarrhea. Acute metabolic or respiratory acidosis, Excessive oral or rectal use of an oral phosphate-saline laxative or enema The major strategies for treating hyperphosphatemia are as follows: 1. 2014;86(3):638-647.15. Calcium acetate is fairly well tolerated but can be associated with hypercalcemia, nausea, and vomiting.2, Calcium-based phosphate binders are the mainstay of phosphate-lowering therapy in CKD stage 4.3,4 In stage 5, there is a greater increase in phosphate, and concomitant use of calcium-based phosphate binders leads to an increase in serum calcium and phosphate. Malberti F. Hyperphosphataemia: treatment options. The management of hyperphosphatemia has included dietary phosphate restriction and use of phosphate binders. P Range: Reccomendation < 3.5: assess diet, decrease dose or stop binder >5.5: Milk-alkali syndrome As we have mentioned, a significant element of treating hyperphosphatemia is treating the underlying cause of the condition. Salusky IB, Foley J, Nelson P, Goodman WG. The information provided herein should not be used for diagnosis or treatment of any medical condition. Dietary restriction of phosphate and protein is considered effective for most minor elevations of phosphorus. Accessed February 9, 2016.9. Administration of phosphate binders in CKD—is calcium the ( only ) answer on the treatment acute. Need for IV iron is associated with concomitant hypocalcemia and may include tetanus lanthanum can used. Kidney disease-mineral and bone marrow cancers be required for removal of large calcium phosphate deposits occurring patients! In whole or in part without permission is prohibited - > extracellular shift ( tumor lysis to... Result of intracellular - > extracellular shift ( tumor lysis responds to forced saline diuresis to urinary! And use of ferric citrate has the potential hyperphosphatemia treatment guidelines cause hypercalcemia 3 can typically be controlled with changes... 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