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Phosphate Binders


 

Calcium Acetate with Magnesium (OsvaRen®), Lanthanum, Sevelamer, Sucroferric Oxyhydroxide

[For Calcium Carbonate please see Calcium Preparations monograph **COMING SOON**]

  Issues for Surgery


Hyperphosphataemia if omitted. 

Risk of gastrointestinal obstruction, ileus, subileus and perforation if continued in patients undergoing major gastrointestinal surgery.

  Advice in the Perioperative period


Elective and Emergency Surgery 
Omit dose(s) while fasting. Phosphate binders should be administered with food and not on an empty stomach1, 2, 3, 4, 5, 6, 7, hence should be held during periods of fasting. Check phosphate levels pre-operatively.

Post-operative Advice 
Restart at patient’s usual dose once eating and drinking.

Monitor phosphate levels post-op – seek advice from Renal specialist if phosphate levels are not within normal limits.

Patients with Post-Operative Swallowing Difficulties  Caution should be exercised in patients taking phosphate binders (except OsvaRen®) who have swallowing difficulties post-operatively, since administration in this group of patients has not been studied2, 3. Consideration should be given to holding phosphate binding medication in these patients until they have regained adequate swallowing function. If swallowing difficulties are likely to remain for a prolonged period post-operatively, advice should be sought from a Renal specialist.   

Patients undergoing Major Gastrointestinal Surgery Exercise caution in patients who have undergone major gastrointestinal surgery due to predisposition to gastrointestinal obstruction, ileus, subileus and perforation2, 3, 4, 7. Advice should be sought from a Renal specialist so that a careful assessment of the risks and benefits can be carried out.

  Interaction(s) with Common Anaesthetic Agents 


Administration of OsvaRen® can result in increased serum calcium levels. This may result in severe arrythmias if adrenaline is administered in such patients6.

  Interaction(s) with other Common Medicines used in the Perioperative Period


Phosphate binders are not absorbed and may affect the bioavailability of other medicinal products1, 2, 3, 4, 5, 6, 7. If administering medication where a reduction in bioavailability could have a clinically significant effect on safety or efficacy (e.g. antimicrobials), administration of the medication should be separated from the phosphate binder, to allow for appropriate absorption1, 2, 3, 4, 5, 6, 7, 8. Please refer to individual product literature for information on recommended time intervals for specific phosphate binders.

Antimicrobials 
Common antimicrobials used in the perioperative period where a significant reduction in bioavailability has been shown or where there is a theoretical interaction include: - 
  • Quinolone antimicrobials (ciprofloxacin, levofloxacin)2, 3, 4, 8
  • Tetracycline antimicrobials (doxycycline)4, 8
Sucroferric oxyhydroxide contains elemental iron and can reduce the absorption of ciprofloxacin and levofloxacin. Since quinolones are rapidly absorbed, taking them 2 hours before sucroferric oxyhydrxide should minimise the risk of admixture in the gut and largely avoid this interaction8.

Proton Pump Inhibitors 
During post-marketing experience, very rare causes of increased phosphate levels have been reported in patients taking proton pump inhibitors co-administered with sevelamer2, 3.

Iron (oral) 
OsvaRen® contains magnesium which can affect absorption of oral iron preparations6. Simultaneous administration of sucroferric oxyhydroxide with oral iron preparations may influence iron absorption8. Administration of oral iron preparations should be separated from OsvaRen· and sucroferric oxyhydroxide to allow for appropriate absorption.

  Further Information


None relevant. 

  References


  1. Joint Formulary Committee. British National Formulary (online) London: BMJ Group and Pharmaceutical Press. http://www.medicinescomplete.com [Accessed on 27th June 2021]
  2.  Summary of Product Characteristics – Renagel® (sevelamer hydrochloride) 800mg film-coated tablets. SANOFI. Accessed via www.medicines.org.uk 27/06/2021 [date of revision of the text August 2019] 
  3. Summary of Product Characteristics – Regagel® (sevelamer carbonate) 800mg film-coated tablets. SANOFI. Accessed via www.medicines.org.uk 27/06/2021 [date of revision of the text January 2021] 
  4. Summary of Product Characteristics – Fosrenol® (lanthanum carbonate hydrate) 1000mg chewable tablets. Takeda UK Ltd. Accessed via www.medicines.org.uk 27/06/2021 [date of revision of the text July 2017] 
  5. Summary of Product Characteristics – Fosrenol® (lanthanum carbonate hydrate) 1000mg oral powder. Takeda UK Ltd. Accessed via www.medicines.org.uk 27/06/2021 [date of revision of the text July 2018]
  6. Summary of Product Characteristics – Osvaren® (calcium acetate + magnesium carbonate, heavy) 435mg / 235mg film-coated tablets. Vifor Fresenius Medical Care Renal Pharma UK Ltd. Accessed via www.medicines.org.uk 27/06/2021 [date of revision of the text March 2017] 
  7. Summary of Product Characteristics – Velphoro® (sucroferric oxyhydroxide) 500mg chewable tablets. Vifor Fresenius Medical Care Renal Pharma UK Ltd. Accessed via www.medicines.org.uk 27/06/2021 [date of revision of the text November 2020] 
  8. Baxter K, Preston CL (eds), Stockley’s Drug Interactions (online) London: Pharmaceutical Press. http://www.medicinescomplete.com [Accessed on 15th March 2021]