- Author: Eleanor Lederer, MD, FASN; Chief Editor: Vecihi Batuman, MD, FACP, FASN more...
Oral phosphate binders are used to decrease the highly efficient gastrointestinal absorption of phosphorus. Calcium salts are widely used but may produce hypercalcemia. Aluminum salts are effective binders but may induce aluminum toxicity. Newer compounds containing iron or bile acid sequestrants are replacing calcium and aluminum binders.
Proximal diuretics are phosphuretic to the same extent that they are natriuretic. Acetazolamide is particularly efficient in promoting renal phosphate excretion.
Diuretics lower phosphate serum levels by enhancing renal excretion.
Furosemide inhibits the resorption of sodium and chloride in the loop of Henle and the proximal and distal tubules of the kidney. Its onset of action is rapid after an intravenous dose. This agent increases the excretion of phosphate.
This agent inhibits carbonic anhydrase, the enzyme that catalyzes the hydration of CO2 and dehydration of carbonic acid. Inhibition reduces reabsorption of NaHCO3 in the proximal tubule, leading to natriuresis, bicarbonate, diuresis, and a decreased serum bicarbonate level. As NaHCO3 delivery to the collecting duct increases, the renal excretion of phosphate increases.
The agents bind to dietary phosphate in the gastrointestinal tract. The phosphate is then eliminated in the feces, thus limiting intestinal absorption.
This agent is a polymeric phosphate binder for oral administration. It does not contain aluminum; thus, aluminum intoxication not a concern.
The polymer forms ionic and hydrogen bonds with phosphates and bile acids to promote fecal excretion. It lowers serum phosphate to near normal levels in hemodialysis patients as effectively as calcium acetate without inducing hypercalcemia or increased aluminum levels. Sevelamer hydrochloride maintains stable intact PTH levels and increases alkaline phosphatase levels compared with calcium acetate.
Lanthanum carbonate is a noncalcium, nonaluminum phosphate binder indicated for the reduction of high phosphorus levels in patients with end-stage renal disease. It directly binds dietary phosphorus in the upper gastrointestinal tract, thereby inhibiting phosphorus absorption.
Sucroferric oxyhydroxide is an iron-based, calcium-free phosphate binder. When it is taken with meals, dietary phosphate is adsorbed in the gastrointestinal tract and eliminated in the feces. It is indicated for the control of serum phosphorus levels in patients with chronic kidney disease on hemodialysis.
Ferric citrate is a phosphate binder. Ferric iron binds dietary phosphate in the GI tract and precipitates as ferric phosphate, which is insoluble and is excreted in the feces. It is indicated for the control of serum phosphorus levels in patients with chronic kidney disease on dialysis.
Aluminum hydroxide, which is available in tablet or liquid form, is commonly used as an antacid. It is not a first-line therapy for hyperphosphatemia, because of the potential for aluminum intoxication with extended use.
This agent normalizes phosphate concentrations in patients on dialysis. Calcium carbonate combines with dietary phosphate to form insoluble calcium phosphate, which is excreted in feces. It is marketed in a variety of dosage forms and is relatively inexpensive. Calcium carbonate is available by tablet for chewing or swallowing and is sold in many sizes (250-1000 mg). It is also used as an antacid or a calcium supplement.
Calcium acetate combines with dietary phosphorus to form insoluble calcium phosphate, which is excreted in feces.
Calcium chloride is administered as an IV preparation; it is used in the treatment of severe symptomatic hypocalcemia. Do not confuse calcium chloride with calcium gluconate; calcium chloride contains approximately 3 times as much elemental calcium per unit weight as calcium gluconate does. In the absence of symptoms, hypocalcemia may be treated with oral supplements rather than IV infusions. Calcium chloride 10% solution contains 100 mg/mL = 1.4 mEq/mL.
Magnesium is a divalent cation that is maximally absorbed in the distal small intestine. At low concentrations, it appears to be absorbed in a saturable carrier-mediated process influenced by vitamin D. At high concentrations, absorption appears to occur largely and inefficiently through diffusion. Magnesium hydroxide reduces the absorption of dietary phosphate.
Calcium gluconate is administered as an intravenous (IV) preparation; it is used in the treatment of symptomatic hypocalcemia, being particularly employed for the treatment of tetany. In the absence of symptoms, hypocalcemia may be treated with oral supplements rather than IV infusions. Calcium gluconate 10% solution contains 100 mg/mL = 0.45 mEq elemental calcium/mL.
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