Sevelamer (
Renagel and Renvela), is an orally administered weakly basic
anion exchange resin that binds dietary
phosphate in the gastrointestinal tract, and is approved for use in the US, Europe and many other countries for the treatment of
hyperphosphatemia in adult patients on
hemodialysis or
peritoneal dialysis. Clinical evidence shows that
sevelamer is at least as effective as
calcium-based oral
phosphate binders in controlling serum
phosphate, but with a lower incidence of
hypercalcemia. Whilst
sevelamer hydrochloride is associated with mild
acidosis,
sevelamer carbonate does not have this drawback. Use of
sevelamer and avoidance of
calcium-based binders may slow the progression of
vascular calcification in
hemodialysis patients, and it also reduces serum
low-density lipoprotein-cholesterol levels. There was no between-group difference in all-cause mortality between
sevelamer and
calcium-based
phosphate binder
therapy in the primary efficacy analysis of the large (n >2100), 3-year DCOR trial. In the smaller (n = 109) nonblind RIND trial in patients new to
hemodialysis, data suggest there may be an overall survival benefit with
sevelamer versus
calcium-based
phosphate binder treatment but the evidence on the efficacy of
sevelamer in reducing mortality and hospitalization is not strong. The balance of evidence, however, does not strongly support the use of
sevelamer over the much less costly
calcium-based binders except in patients at risk of hypercalcemic episodes. Further research into cardiovascular and all-cause mortality over a longer time period would be needed to settle this issue, and the relative survival benefits and cost effectiveness of all
phosphate binder
therapies remains to be fully determined. Despite the relative paucity of data available,
sevelamer has established itself as the most widely used binder in the United States and the most widely used noncalcium-based binder worldwide. However, affordability is a major issue for most health economies and in the light of recent economic events is likely to become more prominent.