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Table 1 Overview of currently available phosphate binders[27, 28, 30, 31, 3537]

From: Hyperphosphatemia in patients with ESRD: assessing the current evidence linking outcomes with treatment adherence

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

  1. GI = gastrointestinal, HCl = hydrochloride.
  2. *Timing and dose of phosphate binder to be adjusted in line with timing of meals/snacks and the phosphorus content thereof.