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Hypophosphatemia in Emergency Medicine Treatment & Management

  • Author: Luda Khait, MD, MS; Chief Editor: Erik D Schraga, MD  more...
 
Updated: Dec 22, 2014
 

Emergency Department Care

Treatment of hypophosphatemia is twofold. 1) correct any precipitating causes of hypophosphatemia, and 2) replace total body phosphates.

  • Depending on the clinical situation, replacement options include dietary phosphate, oral phosphate preparations, and IV phosphate.
  • Replacement of phosphate is recommended through the intravenous route in patients with severe hypophosphatemia and for patients that concomitantly have cardiac dysfunction, respiratory failure, muscle weakness, or impaired tissue oxygenation.[21]
  • Hypophosphatemia and hypokalemia can coexist in certain disorders like diabetic ketoacidosis and alcoholism, so replacement with the potassium salt is most appropriate.
  • The most important consideration in choosing replacement therapy is whether the patient has signs or symptoms of phosphate depletion.
  • Mild to moderately severe, asymptomatic hypophosphatemia
    • Mild to moderately severe, asymptomatic hypophosphatemia may require oral phosphate replacement; however, correcting factors that led to the hypophosphatemia usually is sufficient.
    • In most asymptomatic patients, the serum phosphate level spontaneously normalizes over several days when factors inducing hypophosphatemia are corrected.
    • In patients with minimal symptoms or moderate hypophosphatemia (serum phosphate 1-2 mg/dL), providing oral phosphate replacement may be desirable.
      • It is recommended that oral phosphate replacement be used in patients who are symptomatic and have phosphate levels between 1.0-1.9 mg/dL.
      • For patients who are symptomatic and have a serum phosphate level less than 1.0 mg/dL, IV replacement is recommended, followed by oral replacement once serum phosphate levels reach greater than 1.5 mg/dL.
    • The average adult consumes 1 gram of phosphorus daily. A quart of cow's milk provides this amount of phosphorus (1 mg phosphorus/mL). Dairy products have an additional advantage of supplying absorbable calcium, which can help avoid the hypocalcemia that may result with more aggressive replacement regimens.
    • Phosphorus preparations with sodium and potassium are available, but they have disadvantages, including causing osmotic diarrhea, volume overload, or hyperkalemia.
    • Usual starting doses are 2-3 grams of elemental phosphorus in divided doses.
  • Severe/symptomatic hypophosphatemia
    • Patients with symptoms of hypophosphatemia or with serum phosphate levels less than 1 mg/dL require IV phosphate replacement.
    • IV replacement can be dangerous for the patient, causing an electrolyte disturbances including hypocalcemia, renal failure from calcium phosphate precipitating in the kidneys, and fatal arrhythmias.
    • Serum phosphate concentration should be monitored every 6 hours if replacement is given through the IV route.
    • Once serum phosphate levels reach 1.5 md/dL, therapy should be switched to oral replacement.
    • The intracellular nature of phosphate makes interpreting a low serum phosphate level difficult and predicting the amount required to replenish cellular stores nearly impossible.
    • Accordingly, recommendations for IV phosphate in the literature are varied and based on therapeutic experiences with limited numbers of patients.
    • Avoid hyperphosphatemia when replacing phosphorus intravenously, as this can lead to hypocalcemia (leading to tetany) and calcium-phosphate deposition in tissues (eye, heart, kidney, lung).
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Based on any underlying or suspected etiologies

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Contributor Information and Disclosures
Author

Luda Khait, MD, MS Resident Physician, Department of Emergency Medicine, Detroit Medical Center, Detroit Receiving Hospital

Luda Khait, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Association, Michigan State Medical Society, Emergency Medicine Residents' Association

Disclosure: Nothing to disclose.

Coauthor(s)

Adam J Rosh, MD Assistant Professor, Program Director, Emergency Medicine Residency, Department of Emergency Medicine, Detroit Receiving Hospital, Wayne State University School of Medicine

Adam J Rosh, MD is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Howard A Bessen, MD Professor of Medicine, Department of Emergency Medicine, University of California, Los Angeles, David Geffen School of Medicine; Program Director, Harbor-UCLA Medical Center

Howard A Bessen, MD is a member of the following medical societies: American College of Emergency Physicians

Disclosure: Nothing to disclose.

Chief Editor

Erik D Schraga, MD Staff Physician, Department of Emergency Medicine, Mills-Peninsula Emergency Medical Associates

Disclosure: Nothing to disclose.

Additional Contributors

Robin R Hemphill, MD, MPH Associate Professor, Director, Quality and Safety, Department of Emergency Medicine, Emory University School of Medicine

Robin R Hemphill, MD, MPH is a member of the following medical societies: American College of Emergency Physicians, Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Acknowledgements

Devon J Moore, MD Resident Physician, Department of Emergency Medicine, Wayne State University Detroit Medical Center, Detroit Receiving Hospital

Devon J Moore, MD is a member of the following medical societies: American Medical Student Association/Foundation, Emergency Medicine Residents Association, and Wayne State School of Medicine Black Medical Association

Disclosure: Nothing to disclose.

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