New pharmacotherapy options for hyperphosphatemia

Hyperphosphatemia is an abnormally high level of serum phosphate that contributes to chronic kidney disease (CKD). The management of hyperphosphatemia has included dietary phosphate restriction and use of phosphate binders. The first phosphate binders were aluminum- and magnesium-based antacids. Adverse effects and toxicity limited the use of these agents, and therapy evolved with calcium carbonate, calcium acetate, sevelamer, and lanthanum carbonate. Recently, two iron-based phosphate binders have been approved. Hyperphosphatemia in CKD stages 1 to 3 can typically be controlled with dietary changes. Calcium-based products are often started in stage 4 secondary to efficacy, safety, and cost. In CKD stage 5, hypercalcemia can increase the risk of cardiovascular disease. In this situation, sevelamer and lanthanum have demonstrated a cardiovascular mortality benefit. Sucroferric oxyhydroxide and ferric citrate are calcium-free and may offer benefits in those with a high pill burden and in patients with concurrent anemia, respectively.