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Phosphate binder
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<h2 id="mechanism-of-action">Mechanism of action</h2> <p>These agents work by binding to <a href="/facts/Phosphate/FDGVCxUG">phosphate</a> in the <a href="/facts/GI_tract/nK2zwqBS">GI tract</a>, thereby making it unavailable to the body for absorption. Hence, these drugs are usually taken with meals to bind any phosphate that may be present in the ingested food. Phosphate binders may be simple molecular entities (such as <a href="/facts/Magnesium/XyIhd2FG">magnesium</a>, <a href="/facts/Aluminium/7wmR8jYE">aluminium</a>, <a href="/facts/Calcium/hf252CC0">calcium</a>, or <a href="/facts/Lanthanum/Uhmmy1sB">lanthanum</a> salts) that react with phosphate and form an <a href="/facts/Insoluble/kLE9h3Jb">insoluble</a> compound. </p><p>Calcium carbonate </p><p>Calcium-based phosphate binders, such as calcium carbonate, directly decrease phosphate levels by creating insoluble calcium–phosphate complexes which gets eliminated in the feces.<a class="footnote-ref" id="fnref:1" href="#fn:1"><sup>1</sup></a> </p><p>Lanthanum carbonate </p><p>Non-calcium-based phosphate binders, including lanthanum carbonate, form insoluble complexes with phosphates in food, thereby reducing the amount of phosphate in the body.<a class="footnote-ref" id="fnref:2" href="#fn:2"><sup>2</sup></a> </p><p>Sevelamer carbonate </p><p>Sevelamer is an insoluble polymeric amine, which is protonated once in the intestines and this allows it to bind dietary phosphate. Phosphates are eliminated along with sevelamer, leading to a decrease in the body's phosphate levels.<a class="footnote-ref" id="fnref:3" href="#fn:3"><sup>3</sup></a> </p> <h2 id="medical-use">Medical use</h2> <p>For people with chronic kidney failure, controlling <a href="/facts/Blood_plasma/oHuwwugG">serum</a> phosphate is important because it is associated with <a href="/facts/Bone_pathology/QKm4RGvk">bone pathology</a> and regulated together with serum <a href="/facts/Calcium/hf252CC0">calcium</a> by the <a href="/facts/Parathyroid_hormone/Dh7Uld78">parathyroid hormone</a> (PTH).<a href="https://en.wikipedia.org/wiki/Phosphate_binder#endnote_Lederer">[1]</a> </p> <h2 id="adverse-effects">Adverse effects</h2> <p>Calcium carbonate </p> <ul><li>GI effects (nausea, vomiting, constipation)<a class="footnote-ref" id="fnref:4" href="#fn:4"><sup>4</sup></a></li> <li>Risk of cardiovascular calcification<a class="footnote-ref" id="fnref:5" href="#fn:5"><sup>5</sup></a></li> <li>Risk of hypercalcemia<a class="footnote-ref" id="fnref:6" href="#fn:6"><sup>6</sup></a></li></ul> <p>Lanthanum carbonate </p> <ul><li>GI obstruction<a class="footnote-ref" id="fnref:7" href="#fn:7"><sup>7</sup></a></li> <li>Bile duct obstruction<a class="footnote-ref" id="fnref:8" href="#fn:8"><sup>8</sup></a></li> <li>Hepatic impairment<a class="footnote-ref" id="fnref:9" href="#fn:9"><sup>9</sup></a></li> <li>No hypercalcemia risk<a class="footnote-ref" id="fnref:10" href="#fn:10"><sup>10</sup></a></li></ul> <p>Sevelamer carbonate </p> <ul><li>GI effects (nausea, vomiting, constipation, flatulence)<a class="footnote-ref" id="fnref:11" href="#fn:11"><sup>11</sup></a></li> <li>No hypercalcemia risk<a class="footnote-ref" id="fnref:12" href="#fn:12"><sup>12</sup></a></li></ul> <h2 id="choice-of-agent">Choice of agent</h2> <p>There have been limited trials comparing phosphate binders to placebo in the treatment of hyperphosphatemia in people with chronic kidney disease. When compared with people receiving calcium-based binders, people taking sevelamer have a reduced all-cause mortality.<a class="footnote-ref" id="fnref:13" href="#fn:13"><sup>13</sup></a> </p> <h3>Types</h3> Summary of Common Oral Phosphate Binders<a class="footnote-ref" id="fnref:14" href="#fn:14"><sup>14</sup></a><table><tbody><tr><th>Phosphate Binder</th><th>Brands</th><th>Advantages</th><th>Disadvantages</th></tr><tr><td><a href="/facts/Aluminum_hydroxide/e0pXvDGr">Aluminum salts</a></td><td><i>Alucaps</i></td><td>Calcium free</td><td>Risk of aluminum toxicity</td></tr><tr><td></td><td><i>Basaljel</i></td><td>High binder efficiency regardless of pH</td><td>Requires frequent monitoring-extra cost</td></tr><tr><td></td><td></td><td>Cheap</td><td></td></tr><tr><td></td><td></td><td>Moderate tablet burden</td><td></td></tr><tr><td><a href="/facts/Calcium_carbonate/UQ1wLFna">Calcium carbonate</a></td><td><i>Calcichew</i></td><td>Aluminum free</td><td>Calcium containing-potential risk of hypercalcemia and ectopic calcification</td></tr><tr><td></td><td><i>Titralac</i></td><td>Moderate binding efficacy</td><td>Parathyroid hormone oversuppression</td></tr><tr><td></td><td></td><td>Relatively low cost</td><td>Gastrointestinal side effects</td></tr><tr><td></td><td></td><td>Moderate tablet burden</td><td>Efficacy pH dependent</td></tr><tr><td></td><td></td><td>Chewable</td><td></td></tr><tr><td><a href="/facts/Calcium_acetate/d0ply2tV">Calcium acetate</a></td><td><i>Lenal Ace</i></td><td>Aluminum free</td><td>Calcium containing-potential risk of hypercalcemia and ectopic calcification</td></tr><tr><td></td><td><i>PhosLo</i></td><td>Higher efficacy than calcichew/sevelamer</td><td>Parathyroid hormone oversuppression</td></tr><tr><td></td><td></td><td>Moderately cheap</td><td>Gastrointestinal side effects</td></tr><tr><td></td><td></td><td>Lower calcium load than calcium carbonate</td><td>Large tablets & capsules, nonchewable formulation</td></tr><tr><td><a href="/facts/Sevelamer/dkRChBYt">Sevelamer hydrochloride/Sevelamer carbonate</a></td><td><i>Renagel</i></td><td>Aluminium and calcium free</td><td>Relatively costly</td></tr><tr><td></td><td><i>Renvela</i></td><td>No gastrointestinal absorption</td><td>High pill burden</td></tr><tr><td></td><td></td><td>Moderate efficacy</td><td>Large tablets, nonchewable formulation</td></tr><tr><td></td><td></td><td>Reduces total and low-density lipoprotein cholesterol</td><td>Gastrointestinal side effects</td></tr><tr><td></td><td></td><td></td><td>Binds fat-soluble vitamins</td></tr><tr><td><a href="/facts/Lanthanum_carbonate/nFvxmUjo">Lanthanum carbonate</a></td><td><i>Fosrenol</i></td><td>Aluminum and calcium free</td><td>Relatively costly</td></tr><tr><td></td><td></td><td>Minimal gastrointestinal absorption</td><td>Gastrointestinal side effects</td></tr><tr><td></td><td></td><td>High efficacy across full pH range</td><td>Larger tablet size may cause choking if not chewed well</td></tr><tr><td></td><td></td><td>Chewable formulation</td><td></td></tr><tr><td></td><td></td><td>Palatable</td><td></td></tr><tr><td></td><td></td><td>Low tablet burden</td><td></td></tr><tr><td>Ferric Citrate</td><td><i>Auryxia</i></td><td>Iron based</td><td>Very costly</td></tr><tr><td></td><td></td><td></td><td>Tablets can be toxic to young children</td></tr><tr><td></td><td></td><td></td><td>Stool discoloration - may turn them black, obscuring intestinal bleeding</td></tr></tbody></table> <ul><li><a href="/facts/Calcium_acetate/magnesium_carbonate/rIkGyQdc">Calcium acetate/magnesium carbonate</a></li></ul> <ol><li>^ Lederer E, Ouseph R, Erbeck K. Hyperphosphatemia, eMedicine.com, URL: <a href="http://www.emedicine.com/med/topic1097.htm">Hyperphosphatemia: Practice Essentials, Background, Pathophysiology</a>, Accessed on July 14, 2005.</li> <li>^ Spiegel, David M.; Farmer, Beverly; Smits, Gerard; Chonchol, Michel (2007). "Magnesium Carbonate is an Effective Phosphate Binder for Chronic Hemodialysis Patients: A Pilot Study". <i>Journal of Renal Nutrition</i>. 17 (6): 416–22. <a href="/facts/Doi_(identifier)/muM9Etpq">doi</a>:<a href="https://doi.org/10.1053%2Fj.jrn.2007.08.005">10.1053/j.jrn.2007.08.005</a>. <a href="/facts/PMID_(identifier)/JlHAvMHt">PMID</a> <a href="https://pubmed.ncbi.nlm.nih.gov/17971314">17971314</a>.</li></ol> <h2 id="external-links">External links</h2> <ul><li><a href="https://web.archive.org/web/20050924124247/http://fosrenol.com/Consumers/Default.aspx">High Phosphate Control - Official Fosrenol Homepage</a></li> <li><a href="https://web.archive.org/web/20071018190326/http://aakp.org/aakp-library/Phosphate-Binders--What-Are-They-And-How-Do-They-Work-/index.cfm">Phosphate Binders: What Are They And How Do They Work?</a> - American Association of Kidney Patients*</li> <li><a href="https://web.archive.org/web/20050729114056/http://www.kidney.org.uk/Medical-Info/drugs/phosinf.html">Phosphate Binders</a> - National Kidney Foundation</li> <li><a href="https://web.archive.org/web/20050302034031/http://www.nwkidney.org/images/website/docs/nutrition/phosphate.htm">Phosphate Binders</a> - Northwest Kidney Centers - a center that provides services for people with ESRD in the <a href="/facts/Seattle/7lYIrCa6">Seattle</a> area.</li> <li><a href="https://web.archive.org/web/20070319000733/http://www.phosphoruscontrol.com/Default.aspx">High Phosphate - Phosphorus Control</a> - Information for healthcare professionals on the treatment and management of hyperphosphatemia</li></ul> <h3>Common Phosphate Binders</h3> <ul><li>Hutchison, A. J.; Wilkie, M. (2012). <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4455824">"Use of magnesium as a drug in chronic kidney disease"</a>. <i>Clinical Kidney Journal</i>. 5 (Suppl 1): i62 – i70. <a href="/facts/Doi_(identifier)/muM9Etpq">doi</a>:<a href="https://doi.org/10.1093%2Fndtplus%2Fsfr168">10.1093/ndtplus/sfr168</a>. <a href="/facts/PMC_(identifier)/dX1zMt71">PMC</a> <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4455824">4455824</a>. <a href="/facts/PMID_(identifier)/JlHAvMHt">PMID</a> <a href="https://pubmed.ncbi.nlm.nih.gov/26069822">26069822</a>.</li> <li><a href="https://www.nlm.nih.gov/medlineplus/druginfo/medmaster/a605015.html">Lanthanum</a> - medlineplus.org</li> <li><a href="https://www.nlm.nih.gov/medlineplus/druginfo/medmaster/a601248.html">Sevelamer</a> - medlineplus.org</li> <li><a href="https://www.aubagio.com/?s_mcid=AUWIKI001">Sevelamer</a> - Renvela.com</li></ul> <h2 id="references">References</h2> <ol> <li id="fn:1"><p>Daoud, Kirollos; Anwar, Nihad; Nguyen, Timothy (2023). "The Role of Iron-Based Phosphate Binder in the Treatment of Hyperphosphatemia". Nephrology Nursing Journal. 50 (2): 140. doi:10.37526/1526-744x.2023.50.2.140. ISSN 1526-744X. <a href="https://dx.doi.org/10.37526/1526-744x.2023.50.2.140" target="_blank">https://dx.doi.org/10.37526/1526-744x.2023.50.2.140</a> <a href="#fnref:1" class="footnote-back-ref">↩</a></p></li> <li id="fn:2"><p>Daoud, Kirollos; Anwar, Nihad; Nguyen, Timothy (2023). "The Role of Iron-Based Phosphate Binder in the Treatment of Hyperphosphatemia". Nephrology Nursing Journal. 50 (2): 140. doi:10.37526/1526-744x.2023.50.2.140. ISSN 1526-744X. <a href="https://dx.doi.org/10.37526/1526-744x.2023.50.2.140" target="_blank">https://dx.doi.org/10.37526/1526-744x.2023.50.2.140</a> <a href="#fnref:2" class="footnote-back-ref">↩</a></p></li> <li id="fn:3"><p>Daoud, Kirollos; Anwar, Nihad; Nguyen, Timothy (2023). "The Role of Iron-Based Phosphate Binder in the Treatment of Hyperphosphatemia". Nephrology Nursing Journal. 50 (2): 140. doi:10.37526/1526-744x.2023.50.2.140. ISSN 1526-744X. <a href="https://dx.doi.org/10.37526/1526-744x.2023.50.2.140" target="_blank">https://dx.doi.org/10.37526/1526-744x.2023.50.2.140</a> <a href="#fnref:3" class="footnote-back-ref">↩</a></p></li> <li id="fn:4"><p>Daoud, Kirollos; Anwar, Nihad; Nguyen, Timothy (2023). "The Role of Iron-Based Phosphate Binder in the Treatment of Hyperphosphatemia". Nephrology Nursing Journal. 50 (2): 140. doi:10.37526/1526-744x.2023.50.2.140. ISSN 1526-744X. <a href="https://dx.doi.org/10.37526/1526-744x.2023.50.2.140" target="_blank">https://dx.doi.org/10.37526/1526-744x.2023.50.2.140</a> <a href="#fnref:4" class="footnote-back-ref">↩</a></p></li> <li id="fn:5"><p>Jadav, Paresh R.; Husain, S. Ali; Mohan, Sumit; Crew, Russell (May 2022). "Non calcium phosphate binders - Is there any evidence of benefit". Current Opinion in Nephrology & Hypertension. 31 (3): 288–296. doi:10.1097/MNH.0000000000000796. ISSN 1062-4821 – via Ovid. <a href="https://journals.lww.com/10.1097/MNH.0000000000000796" target="_blank">https://journals.lww.com/10.1097/MNH.0000000000000796</a> <a href="#fnref:5" class="footnote-back-ref">↩</a></p></li> <li id="fn:6"><p>Jadav, Paresh R.; Husain, S. Ali; Mohan, Sumit; Crew, Russell (May 2022). "Non calcium phosphate binders - Is there any evidence of benefit". Current Opinion in Nephrology & Hypertension. 31 (3): 288–296. doi:10.1097/MNH.0000000000000796. ISSN 1062-4821 – via Ovid. <a href="https://journals.lww.com/10.1097/MNH.0000000000000796" target="_blank">https://journals.lww.com/10.1097/MNH.0000000000000796</a> <a href="#fnref:6" class="footnote-back-ref">↩</a></p></li> <li id="fn:7"><p>Daoud, Kirollos; Anwar, Nihad; Nguyen, Timothy (2023). "The Role of Iron-Based Phosphate Binder in the Treatment of Hyperphosphatemia". Nephrology Nursing Journal. 50 (2): 140. doi:10.37526/1526-744x.2023.50.2.140. ISSN 1526-744X. <a href="https://dx.doi.org/10.37526/1526-744x.2023.50.2.140" target="_blank">https://dx.doi.org/10.37526/1526-744x.2023.50.2.140</a> <a href="#fnref:7" class="footnote-back-ref">↩</a></p></li> <li id="fn:8"><p>Daoud, Kirollos; Anwar, Nihad; Nguyen, Timothy (2023). "The Role of Iron-Based Phosphate Binder in the Treatment of Hyperphosphatemia". Nephrology Nursing Journal. 50 (2): 140. doi:10.37526/1526-744x.2023.50.2.140. ISSN 1526-744X. <a href="https://dx.doi.org/10.37526/1526-744x.2023.50.2.140" target="_blank">https://dx.doi.org/10.37526/1526-744x.2023.50.2.140</a> <a href="#fnref:8" class="footnote-back-ref">↩</a></p></li> <li id="fn:9"><p>Daoud, Kirollos; Anwar, Nihad; Nguyen, Timothy (2023). "The Role of Iron-Based Phosphate Binder in the Treatment of Hyperphosphatemia". Nephrology Nursing Journal. 50 (2): 140. doi:10.37526/1526-744x.2023.50.2.140. ISSN 1526-744X. <a href="https://dx.doi.org/10.37526/1526-744x.2023.50.2.140" target="_blank">https://dx.doi.org/10.37526/1526-744x.2023.50.2.140</a> <a href="#fnref:9" class="footnote-back-ref">↩</a></p></li> <li id="fn:10"><p>Jadav, Paresh R.; Husain, S. Ali; Mohan, Sumit; Crew, Russell (May 2022). "Non calcium phosphate binders - Is there any evidence of benefit". Current Opinion in Nephrology & Hypertension. 31 (3): 288–296. doi:10.1097/MNH.0000000000000796. ISSN 1062-4821 – via Ovid. <a href="https://journals.lww.com/10.1097/MNH.0000000000000796" target="_blank">https://journals.lww.com/10.1097/MNH.0000000000000796</a> <a href="#fnref:10" class="footnote-back-ref">↩</a></p></li> <li id="fn:11"><p>Daoud, Kirollos; Anwar, Nihad; Nguyen, Timothy (2023). "The Role of Iron-Based Phosphate Binder in the Treatment of Hyperphosphatemia". Nephrology Nursing Journal. 50 (2): 140. doi:10.37526/1526-744x.2023.50.2.140. ISSN 1526-744X. <a href="https://dx.doi.org/10.37526/1526-744x.2023.50.2.140" target="_blank">https://dx.doi.org/10.37526/1526-744x.2023.50.2.140</a> <a href="#fnref:11" class="footnote-back-ref">↩</a></p></li> <li id="fn:12"><p>Jadav, Paresh R.; Husain, S. Ali; Mohan, Sumit; Crew, Russell (May 2022). "Non calcium phosphate binders - Is there any evidence of benefit". Current Opinion in Nephrology & Hypertension. 31 (3): 288–296. doi:10.1097/MNH.0000000000000796. ISSN 1062-4821 – via Ovid. <a href="https://journals.lww.com/10.1097/MNH.0000000000000796" target="_blank">https://journals.lww.com/10.1097/MNH.0000000000000796</a> <a href="#fnref:12" class="footnote-back-ref">↩</a></p></li> <li id="fn:13"><p>Patel, L; Bernard, LM; Elder, GJ (14 December 2015). "Sevelamer versus calcium-based binders for treatment of hyperphosphatemia in CKD: a meta-analysis of randomized controlled trials". Clinical Journal of the American Society of Nephrology. 11 (2): 232–244. doi:10.2215/CJN.06800615. PMC 4741042. PMID 26668024. <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4741042" target="_blank">https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4741042</a> <a href="#fnref:13" class="footnote-back-ref">↩</a></p></li> <li id="fn:14"><p>Burtis, C.A.; Ashwood, E.R. and Bruns, D.E. Tietz Textbook of Clinical Chemistry and Molecular Diagnostics. 5th Edition. Elsevier. pp1552 <a href="#fnref:14" class="footnote-back-ref">↩</a></p></li> </ol>