noncalcium phosphate binders in CKD

for those of us either treating patients with chronic kidney disease or following them for other reasons, there was an important article in lancet which found that calcium-based phosphate binders are associated with increased mortality (see chr kidney dz and phosphate binders lancet 2013 in dropbox, or http://dx.doi.org/10.1016/S0140-6736(13)60897-1).  this was a meta-anal of 5 new RCTs and 9 older ones  from a previous meta-anal, with 11 reporting mortality as an outcome. 4622 pts involved. compared those on calcium-based phosphate binders (calcium carbonate or calcium acetate) with non-calcium based binders (sevelamer hydrocholride or carbonate -- brand name eg of renagel -- or lanthanum carbonate -- brand name fosrenol). results:

    --overall 22% reduction in all-cause mortality with non-calcium based phosphate binders.  most studies in dialysis patients, but the few with predialysis (only 134 patients) with almost significant 46% decrease in all-cause mortality (0.28-1.03). decreased mortality independent of degree of phosphate reduction
    --for the 7 RCTs which assessed coronary artery calcification, there was a very highly significant decrease in those on non-calcium based formulations vs calcium-based (looked at the Agatston score, for what that's worth)

turns out, not to shock you, that the non-calcium based phosphate binders are a lot more expensive (4-70x), but the patents are due to expire next year.  the background here is that renal failure by itself is highly associated with coronary artery disease (studies suggest that even slightly elevated creatinine levels or even high normal microalbumin levels are associated with higher clinical CAD, and the combo of both has even more association), and the vast majority of renal failure patients die of CAD. so, makes sense to me to switch patients to the non-calcium based binders....

Comments

Post a Comment

if you would like to receive the near-daily emails regularly, please email me at gmodest@uphams.org

Popular posts from this blog

HDL a negative risk factor? or cholesterol efflux??

Although the data on HDL being protective of atherosclerotic disease is pretty consistent, there are negative studies, and the data on medications which dramatically improve HDL levels (eg, the cholesteryl ester transfer protein --CETP --inhibitors, such as torcetrapib) are clinically disappointing. there have been several explanations for this. for example, some HDL particles are "pro-inflammatory" and elicit an atherosclerotic response (which may be related to apolipoprotein C-III). a new article in NEJM highlights another angle -- that the issue is not the HDL number, but HDL's functionality in the reverse transport of cholesterol, as measured by the cholesterol efflux capacity (see  lipids HDL efflux capacity vs amt NEJM 2014 in dropbox, or  DOI: 10.1056/NEJMoa1409065). This article looks at the Dallas Heart Study, where they measured HDL levels, HDL particle concentrations, and cholesterol efflux capacity in 2924 adults free of cardiovascular disease and followed p
Read more

Drug company shenanigans: narcolepsy drug

I have not done a blog for a long time on drug company shenanigans. So it is my great pleasure to bring up a brand-new drug company approach to garner huge amounts of money (see  https://www.nytimes.com/2023/02/28/business/jazz-narcolepsy-avadel-patents.html?smid=nytcore-ios-share&referringSource=articleShare  ).  Based on an article by  Rebecca Robbins of the New York Times, who has written several articles on drug company excesses   As background, this will be my 42 nd  such blog: for the array, see  https://bucommunitymed.wpengine.com/page/4/?s=drug+company+shenanigans   Th e drug company  approach  this time  to extending  their  patents has a few “interesting” angles: -- this is a medication manufactured by Jazz Pharmaceuticals to treat narcolepsy: there are 2 versions: Xyrem and Xywav (Xywav has less sodium, so is marketed to those who should be on a low sodium diet). These meds are basically derivatives of gammahydroxybutyric acid (GHB)      -- the drug actually has a pretty
Read more

UPDATE: ASCVD risk factor critique

  I decided to do an extensive update of my prior ASCVD (atherosclerotic cardiovascular disease) risk analysis and critique of risk calculators, with much more information about the “non-traditional” risk factors. I felt that there should be more data/clarification, since I think we are really undertreating/not preventing the most common cause of death by relying on the ASCVD risk calculators   -- Cardiovascular risk models:      -- many of us rely on the various cardiovascular risk models to determine the appropriate approach to patients, and these are often integrated into the electronic medical records      -- these risk models have several very important limitations:          -- they are typically based on community data, eg from the Framingham study etc. But, in clinical practice, we are dealing with the individual and not the community:              -- there is very clear evidence that there are many individual risk factors that are associated with increased risk of a cardiovascu
Read more