Pharmacology, efficacy and safety of oral phosphate binders

Nat Rev Nephrol. 2011 Sep 6;7(10):578-89. doi: 10.1038/nrneph.2011.112.

Abstract

The ideal serum level of phosphate in patients on dialysis, and the benefits of controlling levels of phosphate in serum remain unclear despite observational studies that associate phosphate levels with mortality. In the absence of robust data from trials, current guidelines are necessarily based on opinion. Oral phosphate binders are required by the majority of patients on dialysis, and all of these binders can control serum levels of phosphate to similar degrees. Patient preference and adherence to prescribed therapy is at least as important as the efficacy of the prescribed binder. Avoidance of calcium-containing binders has become accepted practice where the alternatives are affordable, but incontrovertible evidence in favor of this approach is lacking. Use of sevelamer and lanthanum avoids calcium loading, but at considerable financial cost and with no reliable patient outcome data to prove their value. Additional approaches to aid control of serum levels of phosphate include blockade of gastrointestinal phosphate absorption and possibly binding of salivary phosphate. Importantly, the role of phosphate control in determining patient outcomes must be quantified, which is likely to require a large randomized, controlled study of two levels of phosphate control. Without such a study we will continue to rely on observational data with all its uncertainties and potential to mislead.

Publication types

  • Review

MeSH terms

  • Acetates / therapeutic use
  • Animals
  • Calcium Compounds / therapeutic use
  • Chelating Agents / pharmacology
  • Chelating Agents / therapeutic use
  • Fibroblast Growth Factors / blood
  • Fibroblast Growth Factors / physiology
  • Humans
  • Hyperphosphatemia / drug therapy
  • Hyperphosphatemia / physiopathology
  • Hyperphosphatemia / prevention & control
  • Intestinal Absorption / drug effects
  • Intestinal Absorption / physiology
  • Kidney Failure, Chronic / drug therapy
  • Kidney Failure, Chronic / physiopathology*
  • Kidney Failure, Chronic / therapy*
  • Kidney Tubules, Proximal / physiopathology
  • Lanthanum / pharmacology
  • Lanthanum / therapeutic use
  • Parathyroid Hormone / blood
  • Phosphates / blood*
  • Phosphates / urine
  • Polyamines / pharmacology
  • Polyamines / therapeutic use
  • Renal Dialysis
  • Sevelamer

Substances

  • Acetates
  • Calcium Compounds
  • Chelating Agents
  • Parathyroid Hormone
  • Phosphates
  • Polyamines
  • Fibroblast Growth Factors
  • Lanthanum
  • fibroblast growth factor 23
  • Sevelamer
  • calcium acetate