Sucroferric Oxyhydroxide Research Articles

PUK19 - COST-UTILITY OF SUCROFERRIC OXYHYDROXIDE FOR THE TREATMENT OF HYPERPHOSPHATEMIA IN CHRONIC KIDNEY DISEASE PATIENTS UNDERGOING DIALYSIS IN CANADA

Hyperphosphatemia is a serious and common complication for chronic kidney disease (CKD) patients undergoing dialysis. There is a need for an effective phosphate-lowering therapy. Sucroferric oxyhydroxide (SFOH) has been shown to effectively lower serum phosphate levels in dialysis patients. This study aimed to assess the costs and health consequences of SFOH in the management of hyperphosphatemia for CKD patients undergoing dialysis in Canada. Using a Markov health-state transition model, and the perspective of a publicly funded health care system, we compared the cost-effectiveness of SFOH with sevelamer (SEV) over a 10-year time horizon. The model included multiple health states i.e., on target, off target, alternative treatment on target, alternative treatment off target, renal transplant and death. Off-target patients could switch therapy receiving either SEV or lanthanum carbonate, for SFOH and SEV, respectively. Efficacy data was extrapolated from a pivotal Phase III clinical trial assessing SFOH versus SEV. Costs and utilities were adapted to the Canadian context, using provincial databases and published literature, and were annually discounted at 1.5%. Probabilistic analysis and scenario sensitivity analyses were performed to examine the impact of uncertainty in input parameters. In the base-case deterministic scenario, SFOH resulted in higher per patient incremental costs of C$1,222 and an incremental effect of 0.03 QALYs gained. Higher treatment costs for SFOH are due to a slight mortality benefit for SFOH and higher consumption of costs as a result of increased survival. The incremental cost-utility ratio was estimated at C$37,553 per QALY gained. Probabilistic analysis showed with >60% likelihood that SFOH results in efficient use of healthcare resources in Canada. SFOH appears to be a cost effective treatment in Canada for CKD patients on dialysis with hyperphosphatemia.

Evaluation of changes in ferritin levels during sucroferric oxyhydroxide treatment.

BackgroundA sub-analysis of a Phase III study was conducted to identify factors that might predict increased ferritin levels during long-term sucroferric oxyhydroxide (SO) treatment in hemodialysis patients.MethodsThe open-label, multicenter, Phase III study assessed the efficacy and safety of SO 750–3000 mg/day for 52 weeks in Japanese patients with chronic renal failure and hyperphosphatemia. A total of 125 of 161 patients from the Phase III trial, and who had data for ferritin levels after 28 weeks of SO treatment, were evaluated.ResultsBaseline ferritin was the strongest contributor (P < 0.0001) to ferritin increases during SO treatment. By Week 28, there were significant differences (P < 0.05/3) in ferritin increases between patients with higher [quartile 4 (Q4)] versus lower (Q1, Q2 and Q3) baseline ferritin. An erythropoiesis-stimulating agent dosage reduction was observed in patients with the lowest baseline ferritin level (Q1), and only slight reductions were noted in the other patient subsets. SO dosages administered to patients in baseline ferritin quartiles Q2, Q3 and Q4 were comparable throughout the study with slight fluctuations. SO dosages in Q1 were considerably lower than those in the other quartiles.ConclusionsIn summary, of the baseline variables found to predict increased ferritin, and changes in iron-related parameters, during SO treatment in Japanese chronic kidney disease patients undergoing hemodialysis, baseline ferritin was the most relevant variable.

Phosphate binders for preventing and treating chronic kidney disease-mineral and bone disorder (CKD-MBD).

Phosphate binders for preventing and treating chronic kidney disease-mineral and bone disorder (CKD-MBD).

Effect of Sucroferric Oxyhydroxide on Fibroblast Growth Factor 23 Levels in Hemodialysis Patients

Objective: This study investigated the effects of sucroferric oxyhydroxide on fibroblast growth factor (FGF)-23 and dose reduction of erythropoiesis-stimulating agents (ESA) and intravenous saccharated ferric oxide in hemodialysis patients. Methods: In this prospective, open-label, parallel-group, multicenter trial involving patients receiving lanthanum carbonate hydrate, eligible patients were randomized to a sucroferric oxyhydroxide group or a control group. Hemoglobin, serum phosphate, FGF-23, iron, and ferritin levels, as well as transferrin saturation, doses of intravenous saccharated ferric oxide and ESA administered, and the erythropoietin responsiveness index (ERI) were monitored for 24 weeks. Results: Sixty-eight eligible patients were allocated to receive sucroferric oxyhydroxide (n = 34) or serve as controls (n = 34). Data for 31 patients in the sucroferric oxyhydroxide group and 32 in the control group were analyzed. Serum phosphate was equally well controlled in both groups. In the sucroferric oxyhydroxide group, intact FGF-23 levels decreased significantly from baseline at the end of the study (p = 0.01) and there was a significant difference compared with the control group (p = 0.035). Required doses of ESA and ERI were significantly reduced in the sucroferric oxyhydroxide group decreased significantly. The dose of intravenous saccharated ferric oxide required in the sucroferric oxyhydroxide group was significantly lower than that at baseline (p = 0.006) and in the control group (p = 0.003). Conclusions: Treatment of hyperphosphatemia with sucroferric oxyhydroxide was effective in patients on hemodialysis, resulting in decreased serum FGF-23 levels and a reduction in the required dose of saccharated ferric oxide.

Phosphate Binders Derived from Natural Ores Contain Many Kinds of Metallic Elements Besides Their Active Ingredient Metals.

Most patients undergoing dialysis are required to take many phosphate binder pills to control hyperphosphatemia. Phosphate binders prescribed in Japan are classified into two types: metal-based binders (Ca carbonate, lanthanum carbonate, ferric citrate hydrate, and sucroferric oxyhydroxide) and chemically synthesized polymers (sevelamer hydrochloride and bixalomer). The raw materials of metal-based phosphate binders are natural ores; thus, such binders may contain several other metallic elements. We measured the elemental contents in six metal-based phosphate binders using an inductively coupled plasma mass - spectrometry (ICP-MS) method. As a result, despite being in small amounts, ore-derived phosphate binders contained various elements besides their active ingredient metals: Na, Mg, P, Mn, Fe, Sr, Y, Ba, La, Nd, and Pb in three Ca-based products; Mg, P, Se, Ce, and Gd in one La-based product; and Na, Mg, Al, P, Ca, Ti, Cr, Mn, Co, Ni, Ge, Ba, and La in two Fe-based products. These elements are considered to have originated from pharmaceutical bulk and from pharmaceutical additives. It is unlikely these elements are immediately harmful to patients. However, it should be emphasized that patients undergoing dialysis do not have a urinary excretion route and are administered many phosphate binder pills every day over a long period of time. In the future, pharmaceutical companies may have to disclose standard amounts and/or analytical values regarding the type and quantity of metallic elements in the final formulation or pharmaceutical bulk derived from natural ores.

Sucroferric oxyhydroxide for the treatment of hyperphosphatemia

ABSTRACTIntroduction: Sucroferric oxyhydroxide is a non-calcium, iron-based phosphate binder indicated for the treatment of hyperphosphatemia in patients with chronic kidney disease undergoing dialysis.Areas covered: Herein, the preclinical development and clinical data for sucroferric oxyhydroxide are reviewed, including the key data from the Phase III registration study and the latest evidence from the real-world clinical setting.Expert opinion: Sucroferric oxyhydroxide displays potent phosphate-binding capacity and clinical studies demonstrate its effectiveness for the long-term reduction of serum phosphorus levels in dialysis patients. Observational study data also show that sucroferric oxyhydroxide provides effective serum phosphorus control for hyperphosphatemic patients in the real-world clinical setting. The serum phosphorus reductions with sucroferric oxyhydroxide can be achieved with a relatively low pill burden in comparison with other phosphate binders, which may translate into better treatment adherence in clinical practice. The Phase III data also indicate that sucroferric oxyhydroxide has a favorable impact on other chronic kidney disease-related mineral bone disease parameters, including a fibroblast growth factor-23-lowering effect. Sucroferric oxyhydroxide is well tolerated and associated with low systemic iron absorption, minimizing the potential for iron accumulation or overload. These attributes render sucroferric oxyhydroxide an attractive non-calcium-containing phosphate binder for the treatment of hyperphosphatemia.

Sucroferric oxyhydroxide

Sucroferric oxyhydroxide

Long-term efficacy and safety of sucroferric oxyhydroxide in African American dialysis patients.

Sucroferric oxyhydroxide (SFOH) is a non-calcium, iron-based phosphate binder that demonstrated sustained serum phosphorus (sP) control, good tolerability, and lower pill burden, vs. sevelamer carbonate ("sevelamer"), in a Phase 3 study conducted in dialysis patients with hyperphosphatemia. This analysis evaluates the efficacy and safety of SFOH and sevelamer among African American (AA) patients participating in the trial. Post hoc analysis of a 24-week, Phase 3, open-label trial (NCT01324128) and its 28-week extension study (NCT01464190). Patients were randomized 2:1 to SFOH (1.0-3.0 g/day) or sevelamer (2.4-14.4 g/day) for up to 52 weeks. Of 549 patients who completed the Phase 3 study and extension, 100 (18.2%) AA patients were eligible for efficacy analysis (SFOH, n = 48; sevelamer, n = 52). sP concentrations decreased rapidly and comparably with both treatments by Week 8 (mean ± standard deviation change from baseline: -1.9 ± 1.9 mg/dL for SFOH and -2.2 ± 1.8 mg/dL for sevelamer). These reductions were maintained for 52 weeks (-2.1 ± 2.6 and -2.1 ± 1.6 mg/dL) and achieved with a lower mean pill burden (3.4 ± 1.4 vs. 7.6 ± 2.9 tablets/day) with SFOH vs. sevelamer. Treatment adherence rates (adherence within 70%-120% of expected medication intake) were 79.2% with SFOH and 59.6% with sevelamer. The proportion of patients reporting serious adverse events (AEs) was 27.7% with SFOH and 30.7% with sevelamer. More patients withdrew due to treatment-emergent AEs with SFOH vs. sevelamer (18.5% vs. 8.0%). The most common AEs with both treatments were gastrointestinal-related: diarrhea and discolored feces with SFOH, and nausea, vomiting, and constipation with sevelamer. SFOH is an efficacious and well-tolerated treatment for hyperphosphatemia in AA dialysis patients, with a lower pill burden and an improved adherence rate vs. sevelamer. These findings were consistent with the wider US patient population and the overall study population.

65 Serum Phosphorus Levels and Phosphate Binder Pill Burden of Hemodialysis Patients Who Switch to Sucroferric Oxyhydroxide for 2 Years Compared to Patients Who Discontinue Sucroferric Oxyhydroxide

65 Serum Phosphorus Levels and Phosphate Binder Pill Burden of Hemodialysis Patients Who Switch to Sucroferric Oxyhydroxide for 2 Years Compared to Patients Who Discontinue Sucroferric Oxyhydroxide

208 Combination Phosphate-Binder (PB) Therapy Including Sucroferric Oxyhydroxide (SO) Results in Sustained Improved Phosphorus Control in Difficult to Control Patients; Results of a 1-Year Retrospective Real-World Hemodialysis Cohort

208 Combination Phosphate-Binder (PB) Therapy Including Sucroferric Oxyhydroxide (SO) Results in Sustained Improved Phosphorus Control in Difficult to Control Patients; Results of a 1-Year Retrospective Real-World Hemodialysis Cohort

259 An Economic Analysis of Potential Cost Savings Associated with Switching from Sevelamer to Sucroferric Oxyhydroxide for the Treatment of Hyperphosphatemia in Hemodialysis Patients in A U.S. Setting

259 An Economic Analysis of Potential Cost Savings Associated with Switching from Sevelamer to Sucroferric Oxyhydroxide for the Treatment of Hyperphosphatemia in Hemodialysis Patients in A U.S. Setting

Rationale, design, and characteristics of a trial to evaluate the new phosphate iron-based binder sucroferric oxyhydroxide in dialysis patients with the goal of advancing the practice of E.B.M. (EPISODE)

BackgroundIn dialysis patients, mortality risk due to cardiovascular diseases is remarkably high and prognosis is poor; coronary artery calcification is considered one of the major contributing factors. It is known that hyperphosphatemia is associated with coronary artery calcification. Therefore, controlling serum phosphate level and thereby mitigating vascular calcification could improve the poor prognosis of dialysis patients. However, the optimal phosphate level in dialysis patients remains unknown; hence, this study was planned to compare the effects of two types of non-calcium-based phosphate binders, and examine the effect of strict control of phosphate on coronary artery calcification.MethodsEPISODE is a randomized, open-label, multi-center, interventional trial with a two-by-two factorial design (UMIN ID: UMIN000023648). This trial will enroll hemodialysis patients who have been on dialysis for at least 3 months with a pre-dialysis serum phosphate level of at least 5.0 mg/dL or at least 6.1 mg/dL, respectively, in those taking or not taking a phosphate binder, as measured during the observation period. Registered patients will be randomized to the sucroferric oxyhydroxide or lanthanum carbonate arm and will receive the assigned drug to reduce serum phosphate to two target levels (3.5–4.5 mg/dL in strict arm and 5.0–6.0 mg/dL in standard arm) for 12 months. The primary endpoint will be percent change in coronary artery calcification score, and the secondary endpoints will include change from baseline serum phosphate and calcium levels, change in renal anemia-related factors, etc. The desired sample size has been calculated to be 200 patients.

Real-World Scenario Improvements in Serum Phosphorus Levels and Pill Burden in Peritoneal Dialysis Patients Treated with Sucroferric Oxyhydroxide

Background: A database analysis was conducted to assess the effectiveness of sucroferric oxyhydroxide (SO) on lowering serum phosphorus and phosphate binder (PB) pill burden among adult peritoneal dialysis (PD) patients prescribed SO as part of routine care. Methods: Adult PD patients (n = 258) prescribed SO through a renal pharmacy service were analyzed. Baseline was 3 months before SO prescription. SO-treated follow-up was for 6 months or until either a new PB was prescribed, SO was not refilled, PD modality changed, or patient was discharged. In-range serum phosphorus was defined as ≤5.5 mg/dL. Results: At baseline, mean serum phosphorus was 6.59 mg/dL with 10 prescribed PB pills/day. The proportion of patients achieving in-range serum phosphorus increased by 72% from baseline to month 6. Prescribed PB pills/day decreased by 57% (10 at baseline to 4.3 at SO follow-up, p < 0.0001). The mean length of SO follow-up was 5.1 months; SO follow-up ended for 38, 27, and 50 patients at months 4, 5, and 6, respectively, due to no further PB fills, and for 10, 11, and 4 patients at months 4, 5, and 6, respectively, due to another PB prescribed. In patients with baseline serum phosphorus >5.5 mg/dL who achieved in-range serum phosphorus during SO follow-up for ≥1 quarter, a notable improvement in serum phosphorus (6.54 to 5.10 mg/dL, p < 0.0001) was observed, and there was a 53% reduction in PB pill burden (9.9 to 4.7, p < 0.0001). Conclusion: Among PD patients prescribed SO as part of routine care, improvements in serum phosphorus control and >50% reduction in PB pills/day were observed.

Low Continuity Rate of Sucroferric Oxyhydroxide among Japanese Hemodialysis Patients with High Phosphate Binder Pill Burden

This prospective observational study was conducted to evaluate the continuity, efficacy, and tolerability of sucroferric oxyhydroxide (SO) among hemodialysis (HD) patients who switched to SO from sevelamer hydrochloride (SH) or bixalomer (BX). Participants were 9 HD patients in Kaetsu Hospital who had been receiving more than 9 tablets/d of SH or BX and were switched to SO 750 mg/d. All the participants were men. Over a 6-month observational period, 6 of the 9 patients (67%) discontinued SO because of adverse events, including diarrhea, atheroma, and polycythemia. Although the diarrhea and atheroma were mild, the affected patients did not wish to restart SO. On the other hand, 3 of the 9 patients (33%) continued taking SO throughout the observation period. These patients tended to have increased levels of serum calcium, hematocrit, and serum ferritin; a decreased number of phosphate binder tablets (from 21 tablets/d to 8 tablets/d); and a decreased dosage of erythropoiesis-stimulating agents. Serum phosphate levels tended to decrease in continuers, but tended to increase in discontinuers. It may be preferable to increase the SO dosage gradually rather than switching from SH or BX all at once, and patients who switch to SO should be carefully monitored.

Pharmacological, pharmaceutical and clinical profiles of sucroferric oxyhydroxide (P-TOL® Chewable Tab. 250 mg, 500 mg), a therapeutic agent for hyperphosphatemia

Sucroferric oxyhydroxide (P-TOL® chewable tablets, 250 and 500 mg) is a phosphate binder for oral use; it is composed of polynuclear iron (III)-oxyhydroxide, sucrose, and starches, and is currently indicated for alleviating hyperphosphatemia in patients with chronic kidney disease (CKD) on dialysis. The results of non-clinical pharmacological studies have suggested that P-TOL consistently decreases serum phosphorus levels in the aqueous environment at pH levels similar to those in the gastrointestinal tract, thereby suppressing the progression of secondary hyperparathyroidism, aberrant calcification, and abnormal bone metabolism associated with hyperphosphatemia. Since the diameter of the P-TOL tablet exceeds 15 mm, it is manufactured with a doughnut-shape to minimize choking hazards. From the results of pharmaceutical studies, it was indicated that the P-TOL tablets promptly disintegrated in the gastrointestinal tract and excessive iron uptake from this product is unlikely to occur. In clinical studies, P-TOL (one tablet/dose, t.i.d.) decreased serum phosphorus levels during treatment Week 1 and allowed stable, long-term control of serum phosphorus levels. Furthermore, P-TOL was expected to reduce the tablet burden on patients and to improve medication adherence. The most common adverse reaction was diarrhea. However, in most cases, the symptoms were mild and oral administration of P-TOL could be continued. Although iron-related parameters tended to increase, iron uptake from this product was low, and the risk of iron overload was considered to be low. These findings confirm the efficacy and safety of P-TOL in CKD patients with hyperphosphatemia. Therefore, sucroferric oxyhydroxide therapy is a potentially useful treatment option for hyperphosphatemia.

Efficacy and Safety of Sucroferric Oxyhydroxide and Calcium Carbonate in Hemodialysis Patients

IntroductionIn this phase III, open-label, single-arm, multi-center 12-week study, we evaluated the efficacy and safety of combination therapy with sucroferric oxyhydroxide (PA21) and calcium carbonate for hemodialysis patients with hyperphosphatemia.MethodsWe enrolled 35 subjects aged ≥ 20 years with end-stage kidney disease and serum phosphorus 3.5–6.0 mg/dl who were undergoing hemodialysis 3 times weekly and taking calcium carbonate and sevelamer hydrochloride. Patients switched from sevelamer hydrochloride and calcium carbonate to sucroferric oxyhydroxide and calcium carbonate. Sucroferric oxyhydroxide was orally administered 3 times daily within 750 mg/d (250 mg per dose) to 3000 mg/d (1000 mg per dose), immediately before every meal, for 12 weeks. Calcium carbonate was orally administered 3 times daily after every meal. Outcomes were serum phosphorus concentration, safety, and satisfaction with bowel movements.ResultsMean (SD) serum phosphorus concentrations were 5.01 (0.63) mg/dl at week 0 and 4.89 (1.14) mg/dl at the end of treatment, after patients switched from sevelamer hydrochloride to sucroferric oxyhydroxide. The incidence of adverse drug reactions was 31.4% (11/35), with diarrhea being the most frequent (31.4%). More sucroferric oxyhydroxide-treated patients were satisfied with their bowel movements. More patients with constipation, as well as those who experienced diarrhea, were satisfied with their bowel movements at the end of the study.ConclusionCombined administration of sucroferric oxyhydroxide and calcium carbonate at low doses was effective in maintaining serum phosphorus concentrations within the target range, and patients’ gastrointestinal status improved. Sucroferric oxyhydroxide maintained its serum phosphorus-lowering effect with a decreased pill burden, and its concomitant administration with calcium carbonate was well tolerated.

Pharmacoeconomic Assessment of Sucroferric Oxyhydroxide Vs Sevelamer Carbonate In Patients With Chronic Kidney Disease In Belgium and The Netherlands

Pharmacoeconomic Assessment of Sucroferric Oxyhydroxide Vs Sevelamer Carbonate In Patients With Chronic Kidney Disease In Belgium and The Netherlands

Comparative analysis of the phosphate-binding effects of sucroferric oxyhydroxide, ferric citrate, and lanthanum carbonate

BackgroundIron-based phosphate binders are widely used in hemodialysis, to avoid the increased mortality associated with high serum phosphate in dialysis patients. However, comparative studies on the effects of phosphate binders are currently limited. In the present study, a comparative analysis of ferric citrate (FC), sucroferric oxyhydroxide (SF), and lanthanum carbonate (LC) was performed to assess their primary phosphate-binding and secondary iron uptake capacities.MethodsPatients on maintenance hemodialysis visit our group clinics regularly. The FC, SF, and LC groups comprised 101, 82, and 126 patients, respectively. Subjects were observed from December 2015 to April 2016 (5 months).Serum phosphate levels and other markers were measured in the three medication groups, and changes in phosphate levels and other clinical markers were compared. A drug treatment was considered to be effective if the serum phosphate levels of the patient decreased from baseline in each of the drugs. We evaluated the phosphate-binding capacity compared with each drug using a mixed effect model, for adjusted repeated measured analysis.ResultsSF showed higher phosphate-binding capacity than FC and LC. FC, SF, and LC showed no significant difference in phosphate-binding capacity in the adjusted mixed effect model. However, patients in the FC group exhibited iron accumulation.ConclusionSucroferric oxyhydroxide possesses better phosphate-binding efficacies than ferric citrate and lanthanum carbonate. In addition, ferric citrate showed a strong iron-cumulative effect.

Real-world effectiveness of sucroferric oxyhydroxide in patients on chronic hemodialysis: A retrospective analysis of pharmacy data .

Aims: Hyperphosphatemia has been associated with an increased risk of mortality in patients with end-stage renal disease. We sought to assess the real-world effectiveness of sucroferric oxyhydroxide (SO), an iron-based phosphate binder (PB), in control of serum phosphorus levels, and to determine the associated pill burden in hemodialysis patients. Materials and methods: Adult, in-center hemodialysis patients first prescribed SO through a renal pharmacy service as part of routine clinical care between April 1, 2014 and March 31, 2015 were included in the analysis. The proportion of patients with phosphorus levels ≤ 5.5 mg/dL and the mean prescribed PB pills/day were compared between baseline (3 months prior to SO) and SO follow-up at 3 (SO 1 – 3) and 6 months (SO 4 – 6). Mineral bone disease markers, hemoglobin, iron indices, and erythropoiesis-stimulating agents and intravenous iron use were assessed. Results: At baseline, all patients (n = 1,029) were prescribed PB, and 13.9% had mean serum phosphorus ≤ 5.5 mg/dL. Comparing baseline to SO 1 – 3, the mean prescribed PB pills/day declined from 9.6 to 3.8 pills/day (p < 0.001), and the proportion of patients with serum phosphorus ≤ 5.5 mg/dL increased from 13.9 to 26.1% (+88%). Comparing baseline to SO 4 – 6 (n = 424), the mean prescribed PB pills/day declined from 9.7 to 4.0 pills/day (p < 0.001), and the proportion of patients with serum phosphorus ≤ 5.5 mg/dL increased from 15.6 to 30.4% (+95%). Conclusions: Prescription of SO was associated with an increase in the proportion of patients achieving serum phosphorus levels ≤ 5.5 mg/dL along with fewer prescribed PB pills/day.

A Review of Phosphate Binders in Chronic Kidney Disease: Incremental Progress or Just Higher Costs?

As kidney disease progresses, phosphorus retention also increases, and phosphate binders are used to treat hyperphosphatemia. Clinicians prescribe phosphate binders thinking that reducing total body burden of phosphorus may decrease risks of mineral and bone disorder, fractures, cardiovascular disease, progression of kidney disease, and mortality. Recent meta-analyses suggest that sevelamer use results in lower mortality than use of calcium-containing phosphate binders. However, studies included in meta-analyses show significant heterogeneity, and exclusion or inclusion of specific studies alters results. Since no long-term studies have been conducted to determine whether treatment with any phosphate binder is better than placebo on any hard clinical endpoint (including mortality), it is unclear whether possible benefit with sevelamer represents net benefit of sevelamer, net harm with calcium-containing phosphate binders, or both. Although one meta-analysis suggested that calcium acetate may be more efficacious gram for gram than calcium carbonate as a binder, calcium acetate did not reduce hypercalcemia, and gastrointestinal intolerance was higher. Data are insufficient to determine whether calcium acetate provides lower risk of vascular calcification than calcium carbonate. Fears of lanthanum accumulation in the central nervous system or bone with long-term treatment do not appear to be warranted. Newer iron-containing phosphate binders have potential benefits, such as lower pill burden (sucroferric oxyhydroxide) and improved iron parameters (ferric citrate). The biggest challenge to phosphate binder efficacy is non-adherence. This article reviews the current knowledge regarding safety, effectiveness, and adherence with currently marketed phosphate binders and those in development.