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A Review of Phosphate Binders in Chronic Kidney Disease: Incremental Progress or Just Higher Costs?

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An Erratum to this article was published on 07 August 2017

This article has been updated

Abstract

As kidney disease progresses, phosphorus retention also increases, and phosphate binders are used to treat hyperphosphatemia. Clinicians prescribe phosphate binders thinking that reducing total body burden of phosphorus may decrease risks of mineral and bone disorder, fractures, cardiovascular disease, progression of kidney disease, and mortality. Recent meta-analyses suggest that sevelamer use results in lower mortality than use of calcium-containing phosphate binders. However, studies included in meta-analyses show significant heterogeneity, and exclusion or inclusion of specific studies alters results. Since no long-term studies have been conducted to determine whether treatment with any phosphate binder is better than placebo on any hard clinical endpoint (including mortality), it is unclear whether possible benefit with sevelamer represents net benefit of sevelamer, net harm with calcium-containing phosphate binders, or both. Although one meta-analysis suggested that calcium acetate may be more efficacious gram for gram than calcium carbonate as a binder, calcium acetate did not reduce hypercalcemia, and gastrointestinal intolerance was higher. Data are insufficient to determine whether calcium acetate provides lower risk of vascular calcification than calcium carbonate. Fears of lanthanum accumulation in the central nervous system or bone with long-term treatment do not appear to be warranted. Newer iron-containing phosphate binders have potential benefits, such as lower pill burden (sucroferric oxyhydroxide) and improved iron parameters (ferric citrate). The biggest challenge to phosphate binder efficacy is non-adherence. This article reviews the current knowledge regarding safety, effectiveness, and adherence with currently marketed phosphate binders and those in development.

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Reprinted with permission under the terms of the Creative Commons Attribution-Non-Commercial-No Derivatives License (CC By ND ND); http://creativecommons.org/licenses/by-nc-nd/4.0. Figure citation is Palmer et al. [37]

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  • 07 August 2017

    An erratum to this article has been published.

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Acknowledgements

The authors thank Anne Shaw for manuscript preparation and Nan Booth, MSW, MPH, ELS, for manuscript editing.

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Authors and Affiliations

  1. Department of Pharmaceutical Care and Health Systems, College of Pharmacy, University of Minnesota, Minneapolis, MN, USA

    Wendy L. St. Peter & Eric Weinhandl

  2. Manitoba Renal Program and Winnipeg Regional Health Authority Pharmacy Program, Winnipeg, MB, Canada

    Lori D. Wazny

  3. Department of Pharmacy Practice, Albany College of Pharmacy and Health Sciences, Albany, NY, USA

    Katie E. Cardone

  4. Department of Clinical Pharmacy, College of Pharmacy, University of Tennessee, Memphis, USA

    Joanna Q. Hudson

  5. Department of Medicine,, University of Tennessee, Memphis, USA

    Joanna Q. Hudson

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  1. Wendy L. St. Peter
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Correspondence to Wendy L. St. Peter.

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Conflict of interest

Katie E. Cardone declares she has served on an advisory panel for AstraZeneca and her spouse is employed by Fresenius Medical Care. Eric Weinhandl is also employed by NxStage Medical, but there are no conflicts of interest with the content of this article. Wendy L. St. Peter, Joanna Q. Hudson and Lori D. Wazny declare that they have no conflict of interest.

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An erratum to this article is available at https://doi.org/10.1007/s40265-017-0798-x.

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Peter, W.L.S., Wazny, L.D., Weinhandl, E. et al. A Review of Phosphate Binders in Chronic Kidney Disease: Incremental Progress or Just Higher Costs?. Drugs 77, 1155–1186 (2017). https://doi.org/10.1007/s40265-017-0758-5

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