Current and Future State of Hyperphosphatemia Management

Background: The hyperphosphatemia treatment landscape is evolving with the FDA’s recent approval of tenapanor, the pending availability of generic iron-based phosphate binders, and the prospect of oral-only ESRD medications entering the Prospective Payment System (PPS), also known as the "dialysis bundle," starting January 1, 2025. As nephrologists continue to adjust their hyperphosphatemia treatment approach, they aim to expand the proportion of patients who maintain an optimal phosphorus level and to reduce their medication burden. Methods: Data were collected via independent online surveys of 228 US nephrologists in February and May 2024. Results: While nephrologists report that their use of calcium-based phosphate binders in their hemodialysis patients is declining, treatment rates with sevelamer (46%) and iron-based phosphate binders (16%) are holding steady. With the eventual availability of a generic ferric citrate product, nephrologists project that their use of calcium-based binders and sevelamer will decline, while their use of ferric citrate products and tenapanor will expand. However, the potential for oral-only medications to eventually enter the dialysis bundle is likely to alter their treatment approach further. As nephrologists have become more familiar with tenapanor, the proportion of those who view the agent as a substantial advance in hyperphosphatemia treatment (75%) has expanded over time. Tenapanor’s user base among nephrologists (61%) has continued to increase month-over-month since its launch, as physicians have been prescribing the agent to a higher volume of their dialysis patients. Among the pipeline agents in development for hyperphosphatemia, oxylanthanum carbonate (OLC) has advanced to late-stage clinical development, with most nephrologists expressing interest in the product due to its bioequivalence to lanthanum carbonate, reduced pill burden, and smaller pill size. A substantial proportion of nephrologists (44%) project that OLC will have a definite role in the treatment of hyperphosphatemia. Conclusion: Pending adequate medication access, nephrologists expect to have more treatment options available to them to help reduce the proportion of patients who do not reach their target phosphorus range, along with the potential added benefit of improving quality of life for their hyperphosphatemia patients.