For reducing serum phosphate levels associated with hyperphosphatemia, iron-based binders may be the most efficacious and safe, according to Chinese researchers.

Xiaolei Zhang, MD, of Linyi People’s Hospital in Shandong, China, and colleagues performed a network meta-analysis of 7 phosphate binders versus placebo using randomized controlled trial data from 80 articles involving 16,382 hemodialysis cases. Calcium-based, iron-based, and magnesium-based phosphate-binders were compared directly and indirectly along with lanthanum carbonate, nonabsorbed metal-free polymer, colestilan, and nicotinic acid. Compared with placebo, all phosphate-binding agents reduced serum phosphate levels and serum calcium × phosphorus product, according to findings published online in the Journal of Parenteral and Enteral Nutrition. Based on this single biomarker, iron-based binders appeared the most effective. Phosphate binders had the additional effect of reducing serum intact parathyroid hormone levels.

“Our NMA suggested that iron-based phosphate-binding agents were the most optimal when considering efficacy and safety simultaneously, since it was the best option in serum phosphorus, all-cause discontinuation and it had a satisfactory ranking in other outcomes. In contrast, nicotinic acid was found to be the worst option with poor efficacy overall,” Dr Zhang and colleagues stated.

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Compared with placebo, the iron-based phosphate-binding agents, colestilan, and nicotinic acid were associated with greater risks of adverse events. However, nicotinic acid appeared the most risky.

Mortality and discontinuation of treatment results were similar across binders in this study. In contrast, a 2013 meta-analysis by Jamal et al. (Lancet 2013;382:1268-1277) and a 2016 network meta-analysis by Nigar Sekercioglu et al. linked calcium-based binders with higher mortality (PLoS One 2016;11(6):e0156891). 

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Yang X, Bai Q, Li Y, Liu H, et al. Comparative efficacy and safety of phosphate binders in hyperphosphatemia patients with chronic kidney disease. J Parent Ent Nutr 2017; published online ahead of print. doi: 10.1177/0148607117715440