Table 1 Overview of currently available phosphate binders[27, 28, 30, 31, 35–37]
Phosphate binder | Mechanism of action | Typical daily pillburden* | Advantages | Disadvantages |
|---|---|---|---|---|
Aluminum salts | Aluminum binds to phosphates and forms insoluble precipitate in GI tract; aluminum hydroxide also forms compounds with phosphate ions in the blood | No safe dose identified | Effective, inexpensive | Associated with cognitive disturbances, osteomalacia and anemia. Patient requires careful monitoring |
Calcium acetate (e.g., Phosex®) | Dissociation in GI tract; calcium binds to phosphates and forms insoluble precipitate | 4–6 pills (1000 mg each,equivalent to 250 mgcalcium) per day | Effective and inexpensive | Potential for increased hypercalcemia; could lead to vascular calcification; high pill burden |
Calcium carbonate (e.g., Calcichew) | Dissociation in GI tract; calcium binds to phosphates and forms insoluble precipitate | Pill number as prescribedper day (1250 mg each,equivalent to 500 mg calcium) | Effective and inexpensive | Potential for increased hypercalcemia; could lead to vascular calcification; high pill burden |
Calcium acetate/magnesium carbonate | Dissociation of the active compounds calcium acetate and magnesium carbonate in the GI tract; each binds to phosphate and forms insoluble precipitate | Total: 3–10 pills per day(each pill contains435 mg calcium acetate/235 mg magnesiumcarbonate) | Lower calcium uptake versus calcium-based binders; effective; moderate costs | Monitoring of magnesium level required; in some circumstances, moderate increase in serum magnesium level |
Sevelamer HCl | Anion exchange resin that exchanges chloride ions for phosphate ions | 3 pills (800 mg each) three times daily(Total: 9 pills/day) | Effective; lipid-lowering effect; potential cardioprotective effect | Expensive; high pill burden; associated with GI side effects such as abdominal bloating, diarrhea and constipation. Potential development of metabolic acidosis |
Sevelamer carbonate | Anion exchange resin that exchanges chloride ions for phosphate ions | 3 pills (800 mg each) three times daily(Total: 9 pills/day) | Effective; lipid-lowering effect; potential cardioprotective effect; available as a powder, which may reduce pill burden | Expensive; high pill burden; associated with GI side effects |
Lanthanum carbonate | Dissociation in the upper GI tract; lanthanum then binds to phosphates and forms insoluble, non-absorbable lanthanum phosphate complexes | 1 pill (500 mg, 750 mg or 1000 mg) three times daily (Total: 3 pills/day) | Effective, low pill burden | Expensive; associated with GI side effects such as nausea, vomiting |