PHOS-BIND™ - R X Vitamins

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Starting Dosage: 100 mg/kg/d AL(OH) 3 divided among feedings1 scoop Phos-Bind = 500 mg AL(OH) 3Note: Dosage can be increased safely to as much as 200-300 mg/kg/day ifneeded to maintain serum phosphorus below 6.0 mg/dlChronic Kidney Disease (CKD) in the dog and cat is associated with the development ofrenal secondary hyperparathyroidism and elevated levels of PTH. It is actually the PTHwhich orchestrates many of the pathologies associated with CKD, such as anemia anddepression. By intervening in the course of CKD with the intermittent use of oralcalcitriol (twice weekly), substantial benefits to quality of life and survival times havebeen measured and reported in the literature. PTH testing is helpful, but due to costconcerns, is not always feasible. It has been found that calcitriol can be safely initiatedwith benefits including but not restricted to lowering PTH when the phosphorus is 6.0 orlower, either early in the disease, or following lowering with intestinal phosphate binderssuch as Phos-Bind.THE MANAGEMENT OF CHRONIC KIDNEY DISEASE (Canine & Feline):1. Start Renal diet when patient is in IRIS Stage 2 (late) or a higher IRIS Stage to addressconcerns about muscle mass loss on lowered protein diets when such diets arestarted too early in the disease.2. Maintain serum phosphorus below 5.0 mg/dl using AL(OH) 3 at 100-300 mg/kg/daydivided among feedings; or consider the use of Lanthanum (Fosrenol) at 50-100 mg/kg/day. AL(OH) 3 and Fosrenol can be combined to reduce the cost ofFosrenol and any rare side-effects of the aluminum in the AL(OH) 3 , such astremoring or hypercalcemia.• Sevelamer-based binders may be best avoided as they bind calcitriol in the gutin addition to their binding of phosphorusa. Recheck serum phosphorus 10-14 days after changing dosage or medications3. Serial PTH testing isn’t essential but can be helpful in the management of CKDa. Recheck serum PTH levels 8 weeks after initial dose to evaluate effect whenappropriate4. Twice weekly dosing of calcitriol at 9-10 ng/kg PO at the same numerical houra. Wednesday evening and Sunday morning have been commonly recommendedfor this twice-weekly administration protocol, but other days of the weekare fine as long as the calcitriol is given the night of Day 1 and themorning of Day 4.i. Dose on an empty stomach between mealsb. It has been found that twice weekly dosing of calcitriol is at least as effective asdaily dosing and reduces the chance of hypercalcemiai. If ionized calcium remains high with twice weekly dosing of calcitriol,and its cause is undetermined (idiopathic), it is recommended to useconcurrently a bisphosphonate like Fosamax at 10 mg weekly (ormultiples of that dose) to reduce serum calcium.c. In cases of ionized calcium too low, it is recommended to dose calcitriol on atwice daily basis, using the starting dosage of 2.5 ng/kg/day to boostintestinal calcium absorptionPhos-Bind 2013 2
5. Check ionized calcium in 10-14 days following initiation of calcitriol therapy to checkfor hypercalcemia.IMPORTANCE OF SERUM <strong>PHOS</strong>PHORUS CONTROL IN ANIMALSIt has long been recognized that regulation of blood ionized calcium is vital to health.There are a number of hormones and regulators that maintain adequate calcium levels inthe body. Several of these hormones and regulators also have an important impact uponphosphorus levels.In the past ~10 years a specific class of hormones (phosphatonins) has been discovered.The role of these phosphatonins is primarily to keep serum phosphorus from getting toohigh. These mechanisms of action have been the subject of numerous studies. (3, 6,)The results of these studies have helped us understand that maintaining normal serumphosphorus levels and thus preventing hyperphosphatemia is critical with respect to thehealth of the body. Additionally, these studies into phosphatonin activity have shown thatintestinal phosphate binders, such as Phos-Bind, are essential for use in the uremicpatient.CALCITRIOL BENEFITS1. Down-regulates PTH gene to reduce serum parathyroid hormone (PTH)a. Blocks synthesis of PTH within the parathyroid gland by preventingtranscription of the PTH gene onto mRNA.2. Induces synthesis of the calcium receptor that is required to block the secretion of PTHas well as the calcitriol receptor (VDR) in the parathyroid gland (PTG)3. Prevents parathyroid gland hyperplasia during uremia4. Causes regression of the parathyroid gland from its hyperplastic state in the uremicpatient5. Comprehensive listing of additional benefits of calcitriol are found on Table 1 in thereview article by Galvao et al, 2013.6. The CKD patient administered calcitriol will have both a reduction in azotemia and asubstantial decline in the rate of progression of the renal lesions. These benefitsoccur by several mechanisms of action, including the lowering of PTH levels bythe calcitriol.7. Clinical studies and clinician observations confirm that CKD patients receivingcalcitriol supplementation have significantly prolonged survival times andsubstantially improved quality of life.CAUSES OF LOWERED CALCITRIOL1. In CKD the reduced number of functioning renal tubules reduces the synthesis ofendogenous calcitriol.2. High concentrations of serum phosphorus inhibit 1-hydroxylation of 25-hydroxyvitamin D. Serum phosphorus levels can be so high as to actually stop thesynthesis of calcitriol.3. Serum levels of a phosphatonin, Fibroblast Growth Factor 23, (FGF23) are increasedby serum phosphorus. FGF23 is a critical and powerful early suppressor of renalcalcitriol formation.NOTE: Aluminum hydroxide (Phos-Bind) has proven itself to be a safe, convenientand economical way to manage dietary intake of phosphorus in the CKD patient,especially when used concurrently with calcitriol.Phos-Bind 2013 3
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