Authors

  1. Gasu, Vivian

Article Content

Phosphate binders (PBs), when taken as prescribed, eliminate over 90% of dietary phosphorus from dialysis patients.1,2 In a systematic review presented in this issue of the JBI Database of Systematic Reviews and Implementation Reports, Gasu et al.2 note the effectiveness of PBs when taken as prescribed. Barriers such as pill burden, gastrointestinal discomforts, dose frequency and lack of a support system all play a role in a patient's adherence to PB therapy,2,3 and will be considered in this editorial. The effectiveness of PBs, when used appropriately, has been well documented; therefore, nephrologists, renal dietitians and other healthcare providers are encouraged to carefully guide their patients to overcome barriers to adherence.4 Fissell et al.5 report a steady decrease in serum phosphorus levels when at least one of the barriers to PB adherence is overcome.

 

Among patients with end-stage renal disease, pill burden is the primary barrier to PB adherence because of multiple comorbidities such as diabetes and hypertension present in this population. Dialysis patients take on average 19 pills a day.6 This is one reason why PB quantity is reduced or completely skipped by a large number of patients. This barrier can be overcome when a simple and feasible PB routine is adapted. Instead of taking three tablets per meal of sevelamer carbonate 800 mg (the most commonly prescribed PB), one or two tablets could be taken. However, patients would require education regarding the need for a concomitant increase in either the number of dialysis sessions or duration of each session to allow for more phosphorus removal. Pill burden can also be decreased through the prescription and use of a higher potency PB, such as sucroferric oxyhydroxide 500 mg, for example, which is administered as one chewable tablet with each meal. Sucroferric oxyhydroxide could also aid in decreasing some of the gastrointestinal discomfort (see below) associated with sevelamer carbonate.7

 

Gastrointestinal discomfort, including constipation, diarrhea, dyspepsia and nausea, is another barrier to taking PBs as prescribed. These side effects discourage patients from taking the full dose of PBs as the severity of the discomfort increases with higher doses. In the same systematic review, Gasu et al.2 note that a combination of different PBs can be successfully used for patients who are either experiencing severe constipation from taking sevelamer carbonate or diarrhea from sucroferric oxyhydroxide therapy. Available evidence suggests that the use of a combination of PBs allows for a reduction in the dosage of each PB, which in turn, reduces the discomfort.2

 

Overcoming the barriers to adherence to PBs has been most successful in patients with stronger support systems. The lack of available strong support systems for patients, whether they be healthcare providers, families or friends, can have a grave impact on PB adherence and the wellbeing of this population. Butts and Rich8 stress the importance of a therapeutic alliance between healthcare providers, family members and friends, as this relationship has been shown repeatedly to help generate successful outcomes. Although families and friends assist patients in taking their PBs and adhering to treatment in general, healthcare providers are urged to provide individualized patient-based education, taking into consideration the intellectual, cultural and socioeconomic status of their patient. Mental health issues also need to be considered in instances where nonadherence persists despite the availability of a strong support system.4

 

Barriers associated with PB use will continue to interfere with adherence in the dialysis population. Overcoming these barriers through the adjustment of pills per meal, reduction in gastrointestinal discomforts, and tireless support from healthcare providers, families and friends is promising. However, global data on nonadherence and its associated mortality rate calls for more novel means of reducing the barriers.9,10 All parties involved in helping bridge such gaps in treatment are encouraged to continue to do so on an individual patient basis.

 

References

 

1. Vervloet GM, Sezer S, Massy A, Johansson L, Cozzolino M, Fouque D. The role of phosphorus in kidney disease. Nat Rev Nephrol 2017; 13 1:27-38. [Context Link]

 

2. Gasu V, Ashong M, Seferi A, Fitzpatrick A. Effectiveness of phosphate binders in adult patients with end stage renal disease receiving hemodialysis: a systematic review. JBI Database System Rev Implement Rep 2019; 17 1:49-73. [Context Link]

 

3. Komaba H, Kakuta T, Suzuki H, Hida M, Suga T, Fukagawa M. Survival advantage of lanthanum carbonate for hemodialysis patients with uncontrolled hyperphosphatemia. Nephrol Dial Transplant 2014; 30 1:107-114. [Context Link]

 

4. Marcuccilli M, Chonchol M, Jovanovich A. Phosphate binders and targets over decades: do we have it right now? Semin Dial 2017; 30 2:134-141. [Context Link]

 

5. Fissell RB, Karaboyas A, Bieber BA, Sen A, Li Y, Lopes AA, et al. Phosphate binder pill burden, patient reported non-adherence, and mineral bone disorder markers: findings from the DOPPS. Hemodial Int 2016; 20 1:38-49. [Context Link]

 

6. Chen N, Wu X, Ding X, Mei C, Fu P, Jiang G, et al. Sevelamer carbonate lowers serum phosphorus effectively in haemodialysis patients: a randomized, double-blind, placebo-controlled, dose-titration study. Nephrol Dial Transplant 2014; 29 1:152-160. [Context Link]

 

7. Vervloet M, Marzell B, Stauss-Gabo M, Neuenfeldt C, Ahrens HJ, Cozzolino M, et al. Phosphate binding efficacy of contemporary phosphate binders. 52nd European Renal Association - European and Dialysis Transplant Renal Association Congress - ERA-EDTA 2015; May 28-31, 2015; London (United Kingdom). The Renal Association; 15-A-1073 ERA-EDTA. [Context Link]

 

8. Butts JB, Rich KL. Nursing ethics: across the curriculum and into practice. Sudbury, MA: Jones & Bartlett; 2005. [Context Link]

 

9. Copland M, Komenda P, Weinhandl ED, McCullough PA, Morfin JA. Intensive hemodialysis, mineral and bone disorder, and phosphate binder use. Am J Kid Dis 2016; 68 (5S1):S24-S32. [Context Link]

 

10. Zhai CJ, Yu XS, Yang XW, Sun J, Wang R. Effects and safety of iron-based phosphate binders in dialysis patients: a systematic review and meta-analysis. Ren Fail 2015; 37 1:7-15. [Context Link]