1. Pharmacotherapy Principles and Goals

The core principle of managing phosphate disorders is to balance the urgency of correction against the risks of rapid electrolyte shifts and calcium-phosphate precipitation. This requires a clear understanding of therapeutic targets, appropriate timeframes, and the distinct pathways for repletion versus removal.

Indications for Repletion (Hypophosphatemia)

• Severe Hypophosphatemia: Serum phosphate < 0.32 mmol/L (<1.0 mg/dL).
• Symptomatic Hypophosphatemia: Any level associated with clinical signs such as acute muscle weakness, respiratory failure from diaphragmatic weakness, or cardiac arrhythmias.
• Anticipated High-Volume Losses: Prophylactic repletion is often necessary in patients on continuous renal replacement therapy (CRRT) with phosphate-free solutions.

Indications for Removal (Hyperphosphatemia)

• Chronic Hyperphosphatemia: Primarily in chronic kidney disease (CKD) stages 3–5 to mitigate the risk of vascular calcification and secondary hyperparathyroidism.
• Acute, Severe Elevations: Serum phosphate > 1.5 mmol/L (>4.5 mg/dL), especially in the setting of acute kidney injury or tumor lysis syndrome, where the risk of calcium-phosphate precipitation is high.

2. Hypophosphatemia Repletion

The choice between oral and intravenous repletion depends on the severity of the deficit, the patient’s clinical status, and the integrity of their gastrointestinal tract. Oral supplements are first-line for mild-to-moderate cases, while IV therapy is reserved for severe or symptomatic hypophosphatemia.

2.1 Oral Phosphate Preparations

Oral therapy is the preferred route for most patients. Formulations include sodium phosphate or combination sodium/potassium phosphate tablets and powders (e.g., Neutra-Phos®, K-Phos® Neutral). The typical starting dose is 16–24 mmol of elemental phosphate per day, given in 2–4 divided doses to improve gastrointestinal tolerance. Key considerations include:

• Pharmacokinetics: Bioavailability is approximately 60–80% but can be significantly reduced by concurrent use of antacids or in states of GI hypoperfusion.
• Monitoring: Check serum phosphate every 12–24 hours. Monitor for common side effects like diarrhea and bloating, and be mindful of the sodium and potassium load delivered.
• Advantages/Disadvantages: Oral therapy is safe and low-cost but is limited by a high pill burden and frequent GI side effects.

2.2 Intravenous Phosphate Preparations

IV phosphate is indicated for severe (<0.32 mmol/L), symptomatic, or enterally intolerant patients. Formulations include sodium phosphate and potassium phosphate. Dosing must be cautious and individualized.

• Dosing and Titration: A common starting dose is 0.08–0.16 mmol/kg, infused slowly over 4–6 hours. The infusion rate should not exceed 0.1 mmol/kg/h. As a general rule, each 10 mmol of IV phosphate is expected to raise the serum level by approximately 0.3 mmol/L.
• Warnings and Monitoring: IV phosphate carries significant risks. Monitor serum phosphate, calcium, and potassium during and after the infusion. Rapid administration can cause life-threatening hypocalcemia, hyperkalemia (with potassium phosphate), and metastatic calcification.

3. Management of Hyperphosphatemia

Managing hyperphosphatemia requires a multi-pronged approach that combines dietary restriction, phosphate-binding agents, and, when necessary, renal replacement therapy. The goal is to reduce intestinal phosphate absorption while enhancing systemic clearance.

3.1 Dietary Phosphate Restriction

Patient education is fundamental. The bioavailability of phosphate varies significantly by source: inorganic phosphate additives in processed foods are nearly 100% absorbed, whereas phosphate from animal (~70%) and plant (~40%) sources is less available. Key strategies include avoiding processed foods, reading labels for ingredients containing “phos,” and counseling with a renal dietitian.

3.2 Phosphate Binders

Binders are taken with meals to trap dietary phosphate in the gut, preventing its absorption. The choice of agent depends on the patient’s serum calcium level, vascular calcification risk, and side effect profile.

4. Special Populations and Dose Adjustments

Pharmacotherapy must be tailored to account for age, renal replacement modality, and underlying nutritional status.

4.1 CRRT Patients

CRRT causes significant phosphate losses, proportional to the effluent (ultrafiltration + dialysate) rate. Prophylactic repletion is often required. Options include scheduled enteral phosphate or the use of phosphate-enriched replacement/dialysate fluids. A starting dose of 0.16 mmol/kg/day of enteral phosphate with serial monitoring is a reasonable approach.

4.2 Pediatrics and Geriatrics

• Pediatrics: Dosing is strictly weight-based (e.g., 0.1 mmol/kg for IV repletion). Frequent monitoring is critical due to a larger extracellular fluid volume relative to adults and dynamic metabolic needs.
• Geriatrics: “Start low and go slow” is the guiding principle. Reduced GI absorption, polypharmacy, and decreased renal clearance necessitate slower dose escalation and careful monitoring.

4.3 Refeeding Syndrome

In malnourished or post-surgical patients, re-introduction of nutrition triggers an insulin surge, driving phosphate into cells and causing profound hypophosphatemia. Repletion must be proactive and cautious. Start with low-dose IV phosphate (e.g., 0.08 mmol/kg) and titrate slowly. Concurrent administration of thiamine and multivitamins is essential to support metabolic recovery.

5. Pharmacoeconomics and Resource Utilization

The choice of therapy has significant implications for cost, nursing workload, and patient adherence.

• Acquisition Costs: Oral phosphate is inexpensive (~$0.10/mmol), whereas IV preparations require compounding, adding pharmacy and nursing costs. Among binders, generic calcium-based agents are cheapest (<$0.50/pill), while newer agents like sevelamer (~$2/pill) and tenapanor (~$15/day) are substantially more expensive.
• Pill Burden: Adherence to phosphate binders is notoriously poor, especially when the pill burden exceeds 8-10 pills per day. This can favor more potent or combination therapies despite higher costs.
• Nursing Time & Waste: IV repletion is labor-intensive, requiring pump setup, monitoring, and frequent lab draws. Enteral replacement reduces nursing workload and significantly decreases plastic and pharmaceutical waste.