Sevelamer treatment strategy in peritoneal dialysis patients: conventional dose does not make best use of resources.
BACKGROUND
The significant incremental expense in the use of conventional sevelamer dose prompted us to evaluate the role of prescribing a lower dose of sevelamer.


METHODS
To determine the optimum strategy for prescribing sevelamer in peritoneal dialysis patients, we conducted an open-label randomized study comparing the treat-to-goal strategy (4.0-g daily sevelamer dose) with lower sevelamer dose (1.2-g daily dose).


RESULTS
Twenty-seven peritoneal dialysis patients with serum calcium x phosphorus product above 55 mg2/dL2 were recruited. Eighteen were randomized to the low-dose treatment group (1.2 g daily), and 9 to the treat-to-goal (4.0 g daily) group. Overall, significantly lower calcium x phosphorus product and serum phosphorus levels at 6 months were achieved by the treat-to-goal treatment. The proportions of patients who attained the Kidney Disease Outcomes Quality Initiative (K/DOQI) treatment target, however, did not differ significantly between the treat-to-goal and low-dose treatment groups (66.7% +/- 30.8% vs. 33.3% +/- 21.8%, p=0.10). The numbers needed to treat to benefit 1 patient who attains the K/DOQI recommendation are 1.5 patients (95% confidence interval [95% CI], 1.0-2.8) in the 4.0-g daily dose and 3 patients (95% CI, 1.8-8.7) in the 1.2-g daily dose group. Therefore, an extra 66.7% of subjects would be able to attain the treatment recommendation within the same budget if the daily dose of sevelamer used was 1.2 g instead of the usual 4.0 g. Compared with a 1.2-g daily dose of sevelamer, the 4.0-g daily dose had an incremental cost-effectiveness ratio (ICER) of US $2,353 per additional patient achieving the K/DOQI target. Multivariate analysis showed that only the calcium x phosphorus product after 1 month of sevelamer treatment was predictive of treatment response.


CONCLUSIONS
Low-dose sevelamer treatment might be a cost-effective approach, which is "good for many rather than best for a few."
Department of Medicine and Therapeutics, Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, Hong Kong, China. Chow_Kai_ming@alumni.cuhk.net
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Chow
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Szeto
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Kwan
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Leung
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Li
D000328:Adult; D000368:Aged; D002614:Chelating Agents / Q000008:administration & dosage*; D003362:Cost-Benefit Analysis; D004305:Dose-Response Relationship, Drug; D005260:Female; D006801:Humans; D054559:Hyperphosphatemia / Q000188:drug therapy* / Q000209:etiology; D008297:Male; D008875:Middle Aged; D010530:Peritoneal Dialysis / Q000009:adverse effects*; D010758:Phosphorus; D011073:Polyamines / Q000008:administration & dosage*; D000069603:Sevelamer
D002614:Chelating Agents; D011073:Polyamines; D010758:Phosphorus; D000069603:Sevelamer