Overall, only 52% of patients had serum phosphorus levels within recommended ranges. Increased pill burden from phosphate binders is associated with reduced adherence, with almost 40% of patients reporting taking less than 80% of the prescribed dose at an average of 8.3 pills per day. Adherence declines further with higher pill burdens, with medication possession ratios ranging from 51% in patients with the lowest burden to 42% in patients with the highest. Patients who skipped their phosphate binder pills were more likely to have elevated serum phosphorus levels. Common reasons for non-adherence included forgetting doses and not feeling well.

1. Adherence

2. Overall, only 52% of patients had serum phosphorus
concentrations within the KDOQI-recommended range
1 © Galenica Group 04.07.14 Fernández-Martin JL, et al. Nephrol Dial Transplant 2013;28:1922–1935
*K/DOQI-recommended ranges: serum phosphorus, 3.5–5.5 mg/dL; serum calcium, 8.4–9.5 mg/dL; serum PTH, 150–300 pg/mL
**K/DIGO-recommended ranges: serum phosphorus, 3.0–4.5 mg/dL; serum calcium, 8.5–10.2 mg/dL; serum PTH, 10–65 pg/mL
0
10
20
30
40
50
60
70
80
90
Calcium Phosphorus PTH
K/DOQI targets*
K/DIGO targets**
Patients
(%)
Serum levels within targets
58
77
52
27 29
56
Patients in Western European
and Mediterranean countries
had better controlled
biochemical parameters
(Ca, P, PTH)

3. Increased pill burden is associated with reduced adherence to
phosphate binders (PB)
2 © Galenica Group 04.07.14
CI=confidence interval
Chiu YW, et al. Clin J Am Soc Nephrol 2009;4(6):1089–1096
At an average pill burden of
8.3 pills/day, almost 40% of
patients reported taking <80%
of the prescribed dose
0
20
40
60
80
100
3–5 6–8 9–11 12 13–32
Adherence
(%)
Pill burden from phosphate binders

4. Adherence expressed through Medication Possession Ratio
(MPR) declines with increasing phosphate binder pill burden
3 © Galenica Group 04.07.14 Wang S, et al. Nephrol Dial Transplant 2013 [Epub ahead of print]
MPR: the proportion of days in the reporting period that the patient had sufficient pills available to take as prescribed
• Overall, mean weighted MPR levels are low, ranging from 51% (order method) in patients with the lowest
pill burden to 42%, respectively, in patients with the highest pill burden
Order method

5. DOPPS: patients who skipped their PB pills, more likely to
have reduced serum P control
4 © Galenica Group 04.07.14
Patients who skipped PB
treatment more likely to
have serum P levels >5.5
mg/dL
Adapted from Tentori F, et al. ASN. 2012; Poster and Abstract (abstract # SA-PO665)
3.00
1–3
times
3–6
times
> 6
times
Number of times PB skipped in past month
(Ref.)
Odds Ratio (95% CI) of P >5.5 mg/dL
Took all
PB pills
2.50
2.00
1.75
1.50
1.25
1.10
1.00
0.90
0.80
Note: Model additionally adjusted for number of PB pills/day
Test for trend: p<0.001

6. Reasons for Non-Adherence with Phosphate Binders
5 © Galenica Group 04.07.14 Adapted from Tomasello S, et al. Dial Transplant 33: 236-242, 2004)
*non-adherence judged when adherence ≤ 80%
†Adherent patients who missed their binder doses, eating out accounted for 19 of 36 non-adherent episodes
Reasons for missing binder doses in non-adherent patients Non-adherence Rate*
(n)
Too many pills 4 (6%)
Forgot 21 (30%)
GI upset 3 (4%)
Eating out† 6 (8%)
Too big to carry 3 (4%)
Too big to swallow 1 (1%)
Not much for pills 1 (1%)
Did not feel well 2 (3%)
Unaware of correct prescription 26 (37%)

7. Serum phosphate levels are often not adequately controlled
• Effectiveness of therapy is compromised by adherence to therapy
• Adherence is affected by the high pill burden in HD patients and
tolerability of available drugs
• Additional phosphate binder therapy options are required
6 © Galenica Group 04.07.14

8. Potential ways to improve medication adherence
• Reduce pill burden
• Simplifying dosing regimens
• Ease of intake
• Palatability/aste
• Improve tolerability of medication
• Improve patient education
7 © Galenica Group 04.07.14

9. Interested in this topic?
Please feel free to download our articles (Part 1-8) on
adherence from our service center.
8 © Galenica Group 04.07.14