In some patients, the use of calcium-based phosphate binders can cause hypercalcemia; thus, calcium-free preparations are desirable. In addition, many patients with CKD are iron-deficient. Use of ferric citrate may mitigate the need for IV iron and erythropoietin-stimulating agents, which should be used with caution if used concomitantly. IV iron is associated with an increased risk of infection.
This has not been reported in iron-based phosphate binders, but it remains a consideration. Sucroferric Oxyhydroxide: The first iron-based phosphate binder, sucroferric oxyhydroxide Velphoro , was approved in Sucroferric oxyhydroxide uses a ligand exchange reaction with hydroxyl molecules to bind phosphorus in the GI tract. The active form of the drug is insoluble and cannot be metabolized or absorbed.
Sucroferric oxyhydroxide was found to be noninferior to sevelamer carbonate in reducing serum phosphate in an open-label clinical trial of 1, patients. The tablets should not be swallowed but can be chewed or crushed.
The most common adverse effects of sucroferric oxyhydroxide in clinical trials were diarrhea, discolored feces black , nausea, and abnormal taste. Sucroferric oxyhydroxide has not been studied in patients who had conditions where iron accumulation is common or who had GI disorders. Caution should be used in patients who have peritonitis during peritoneal dialysis or hemochromatosis and immediately after GI surgery.
Sucroferric oxyhydroxide has been studied in clinical trials for up to 52 weeks. Ferric Citrate: Ferric citrate Auryxia is an oral iron-based phosphate binder that was approved by the FDA in for management of hyperphosphatemia in patients with CKD on dialysis. Iron in the ferric form binds phosphate in the GI tract and forms a precipitate of ferric phosphate, which is then excreted as fecal matter.
Package labeling indicates a starting dose of 2 tablets orally 3 times per day with meals, adjusting the dose by 1 to 2 tablets as needed to maintain serum phosphorus levels at target, with the maximum being 12 tablets daily. This iron-containing product is contraindicated in iron-overload syndromes such as hemochromatosis. Patients should be monitored regularly for iron overload. Ferric citrate has the potential to decrease the absorption of doxycycline.
Common adverse effects from clinical trials include diarrhea, discolored feces dark , constipation, nausea, and vomiting. The pharmacist should be able to recognize when oral phosphate binders are needed and be familiar with the risks and benefits of available treatments. Additionally, pharmacists should be able to recommend patient-specific phosphate binders based upon electrolyte, anemic, and diabetic status, as well as infection risk. Finally, the pharmacist is in a key position to help patients optimize therapy with an understanding of drug interactions, adverse effects, medication costs, and overall pill burden.
Oral phosphate binders are widely used in clinical practice for patients with end-stage renal disease. It should be recognized that all phosphate binders have equal ability to maintain serum phosphorus in the targeted level provided the patient is compliant and tolerant of the treatment regimen. Calcium-based phosphate binders are often used for CKD stages 3 to 5; they are inexpensive, but have a potential to cause hypercalcemia. Recent advancements have been made in phosphate-binder treatment.
Sevelamer and lanthanum can be used in the setting of hypercalcemia, and they offer a cardiovascular mortality benefit. The recently approved iron-based products may have a role in certain patients, but the long-term safety risk of these products has not been established.
It is important for the pharmacist, as an essential member of the healthcare team, to be familiar with these new treatments in order to optimize therapy in the setting of hyperphosphatemia. Fluids and electrolytes. Pharmacotherapy Principles and Practice. Oral phosphate binders in patients with kidney failure. N Engl J Med. Kidney Int. National Kidney Foundation. Am J Kidney Dis. Hyperphosphatemia and phosphate binders. Am J Health Syst Pharm.
If you miss a dose of this medicine, take it as soon as possible. However, if it is almost time for your next dose, skip the missed dose and go back to your regular dosing schedule. Do not double doses. Store the medicine in a closed container at room temperature, away from heat, moisture, and direct light. Keep from freezing. It is very important that your doctor check your progress at regular visits, especially during the first few months of treatment with this medicine, since your dose may have to be adjusted.
This is to make sure that this medicine is working properly and does not cause unwanted effects. Blood tests may be needed to check for unwanted effects. Sometimes, you might have hypercalcemia too much calcium in the blood and not have any warning signs. You may need to have blood tests on a regular schedule while you are being treated with this medicine to check the amount of calcium and phosphorus in your blood. Keep all appointments your doctor makes for you.
If you have mild hypercalcemia, you may lose your appetite and have nausea, vomiting, or constipation. If the problem is severe, you may feel confused or extremely excited. Stop using this medicine and call your doctor right away if you think you might have severe hypercalcemia. Do not take other calcium-containing products including dietary supplements and antacids.
Your doctor may adjust the amount of calcium-containing foods you eat. Taking too much calcium while you are taking this medicine can cause hypercalcemia.
Along with its needed effects, a medicine may cause some unwanted effects. Although not all of these side effects may occur, if they do occur they may need medical attention. Some side effects may occur that usually do not need medical attention.
These side effects may go away during treatment as your body adjusts to the medicine. Also, your health care professional may be able to tell you about ways to prevent or reduce some of these side effects. Check with your health care professional if any of the following side effects continue or are bothersome or if you have any questions about them:.
Other side effects not listed may also occur in some patients. Can be crushed and mixed with applesauce. Women and children should not manipulate capsule. Tablet is scored. Swallow the tablet whole.
Swallow whole tablet. Do not open, chew nor crush capsule. Do not cut crush or chew tablet. Do not chew or crush. Cefuroxime generic coated tablet. Do not chew microgranules. Bitter taste may be unacceptable to patient. Risk of fatal overdose if chewed, crushed or disolved. Taste may be unacceptable to patient. Do not cut crush nor chew. Skin irritant. See Procytox. The mg tablet is enteric coated.
Desipramine generic film coated tablet NO See comment Taste may be unacceptable to patient. Can be dissolved in a glass of water. Drink immediately, followed by another glass of water. Can be disolved in a glass of water. Diltiazem HCL ER generic aand Diltiazem T generic extended release capsule NO NO Capsule may be opened and the contents taken without crushing and chewing mixed with applesauce, or in a glass of water and taken immediately.
Diltiazem SR and CD generique controlled delivery capsule NO NO Capsule may be opened and the contents taken without crushing and chewing mixed with applesauce, or in a glass of water and taken immediately. Crumbly tablet. Do not cut crush chew or dissolve in mouth. May be absobed through skin. NO NO A part of capsule is extended release and other part immediate release. Do not open or modify. Drink immediately.
Convulsions risk if tablet is modified. Flurbiprofene generic tablet NO NO Crushed sucked or chewed tablets may cause oropharyngeal irritation. Flutamide generic tablet See comment See comment Antineoplastic.
May be dissolved in water or apple juice 50ml for mg and ml for mg tablet. Skin and mucous membrane irritant. Do not chew granules - risk of serious overdose. GI upset possible if crushed. Bad taste if crushed. Do not cut chew or crush tablet. Bad taste. Do not cut, crush nor chew. Drink immediately, rince glass with water and drink content.
Do not alter. Compound for nasogastric use: Dissolve 1 tablet in 40ml of water and mix for 10 minutes. Teratogenic and may be absorbed by skin. Mix 30 seconds and drink content without chewing pellets. Coating masks bad taste. Bitter taste.
Do not take if tablet altered. Manipulate with caution. Do not chew cut or crush tablet. Do not cut chew nor crush. Danger of severe overdose if crushed or chewed.
NO NO Nitrofurantoin regular tablet 50 or mg. Do not open capsule. Swallow whole tablet immediatly after removing from blister. Only the mg tablet may de divided in 2.
Breaking chewing or crushing the tablet can release a potentielly fatal morphine dose. Hard coating tablet. Capsule may be opened and the content mixed with orange juice or applesauce. Mix and drink immedialty, do not chew pellets. Sublingual tablet. Breaking chewing or crushing the tablet can release a potentielly fatal oxycodone dose.
Avoid mixing with dairy products. Active ingredients released in small intestine and colon.
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