1. Association of Niacin on Phosphate Control in Advanced-Stage CKD Patients
Nick Burge, PharmD, BCPS
Clinical Pharmacy Specialist, Nephrology
Edward Hines, Jr. VA Hospital

2. I have no conflicts of interest to disclose.
The viewpoints presented today are my own, and do not necessarily reflect the position or policies of the Department of Veterans Affairs or the US Government.
Opinions presented today are not that of the Department of Veterans Affairs

3. Objectives Review the history of niacin use
Outline findings of our and other studies for niacin and hyperphosphatemia
Identify patients who may be candidates for therapy
Review strategies for optimizing phosphorus control

4. Mineral and Bone Disorder Pathway1
Decreased GFR (<30 mL/min)
Decreased Phosphate Elimination
Increased Phosphate
Increased PTH
Decreased Active Vitamin D
Decreased Calcium Absorption
Decreased Phosphate Absorption
Adapted from DiPiro?
Citation: Hudson JQ, Wazny LD. Hudson J.Q., Wazny L.D. Hudson, Joanna Q., and Lori D. Wazny.Chronic Kidney Disease. In: DiPiro JT, Talbert RL, Yee GC, Matzke GR, Wells BG, Posey L. DiPiro J.T., Talbert R.L., Yee G.C., Matzke G.R., Wells B.G., Posey L Eds. Joseph T. DiPiro, et al.eds. Pharmacotherapy: A Pathophysiologic Approach, 10e New York, NY: McGraw-Hill; . Accessed October 22, 2017
***Check and change as needed (dec vit d decreased calcium
Main focus today is on phosphorus control?
Adapted from: DiPiro JT, et al. Pharmacotherapy: A Pathophysiologic Approach. Figure 44-2

5. Results of of poorly controlled phosphorus2-3
Each 1mg/dL increase in serum phosphorus was linked to a estimated 23% increased risk of mortality
Serum phosphate concentrations greater than 6.5 mg/dL have been independently associated with an increased morbidity and mortality in patients on hemodialysis
Dialysis-related itching
Calcifications
Kestenbaum B et a JASN 2005;16(2)
(Serum phosphate)- citations: Block  GA, Klassen  PS, Lazarus  JM,  et al. Mineral metabolism, mortality and morbidity in maintenance hemodialysis. J Am Soc Nephrol 2004;15:2208–2218. Accessed: 24 October 2015.
Block  GA. Therapeutic interventions for chronic kidney disease-mineral and bone disorders: focus on mortality. Curr Opin Nephrol Hypertens 2011;20:376–381
Chart available stating average mortality for phosphate levels
Likely U-shaped curve that is explained by either malnutrition or poor phosphate control

6. Mechanisms to Control Phosphorus
Dietary Restriction
Phosphate Binders
Dialysis
Look up average phosphorus removed from a dialysis treatment

7. Mechanisms to Control Phosphorus
Dialysis
Not every patient with CKD would require dialysis
Insufficient on its own to maintain phosphorus levels
Look up average phosphorus removed from a dialysis treatment
Would need closer to hours of HD/week to eliminiate need for phos binders from some studies

8. Mechanisms to Control Phosphorus
Dietary Restriction
Difficult to determine phosphate content of food
Protein Needs/Malnutrition
Phosphate additives = highly bioavailable
Look up average phosphorus removed from a dialysis treatment

9. Mechanisms to Control Phosphorus
Phosphate Binders
Medications- Phosphate Binders
Calcium-based phosphate binders
Non-Calcium based phosphate binders
Iron-based phosphate binders
Look up average phosphorus removed from a dialysis treatment

10. Phosphate Binders Mechanism of Action1
Bind to dietary phosphate within intestinal lumen forming an insoluble complex preventing absorption
Blood
Phosphate
Phosphate Binder
Picture- courtesy of someone?
Draw one?
Enterocyte
Lumen

11. Comparison of Binder Costs4-9
Cost/month
Calcium Carbonate
(500mg elemental)
Calcium Acetate
(667mg)
Sevelamer
(800mg)
Lanthanum
(500mg)
Ferric Citrate
(210mg)
Sucroferric Oxyhdroxide
Average Wholesale Price (AWP)
$0.90
$157
$548
$1167
$577
$1243
References- Lexi-comp AWP
Medication Part D-
Entanercept. Lexi-Drugs. Lexicomp. Wolters Kluwer Health, Inc. Riverwoods, IL.  Available at:  Accessed August 24, 2016.
Price estimates obtained from Lexi-Comp

12. Audience Participation!
In your clinics or dialysis-centers, what type of phosphate binders do you see most often being used first-line?
Calcium-based phosphate binders (calcium carbonate or calcium acetate)
Non-Calcium based phosphate binders (sevelamer or lanthanum)
Iron-based phosphate binders (ferric citrate or sucroferric oxyhydroxide)
Aduience response asking what phos binders are often seen in your practice (ca-based, non-Ca-based,

13. Issues related to phosphate binder usage10-11
Calcifications
Pill Size
Dental Issues/Taste with chewables
Pill Burden
Calcifications: Jamal SA, Vandermeer B, Raggi P, et al. Effect of calcium-based versus non-calcium-based phosphate binders on mortality in patients with chronic kidney disease: an updated systematic review and meta-analysis. Lancet. 2013; 382:
Pill burden: Chiu Y, Teitelbaum, I, Misra M, et al. Pill burden, adherence, hyperphosphatemia, and quality of life in maintenance dialysis patients. Clinical Journal of the American Society Nephrology Jun;4(6): doi: / CJN Epub 2009 May 7.
-Falling out of favor of calcium-based binders
-Many patients saying that after taking their binders they are barely hungry enough to eat
-Numerous dental issues either precluding chewing tablets, or added difficulty of needing to acquire a crusher to do the job
One patient who states stigma of having to crush up lanthanum into a fine powder in public
-Also known as the number of pills that patient takes in a day. This will come up later on, but studies have shown that CKD/ESRD has the highest pill burden of any chronic disease

14. Niacin (Vitamin B3)12-13 Dietary sources
Historically used for control of dyslipidemia
Was commonly used as a second-line agent to statins if levels were not adequate controlled
Favorable due to benefits on lipids
Lab Parameter
Effect
LDL
↓ 5-10 mg/dL
HDL
↑ mg/dL
Triglycerides (TGs)
↓ mg/dL
Decreases phosphorous absorption by direct inhibitory effect of nicotinamide (or niacinamide), a niacin metabolitce, on active Na-Phosphate cotransporter in the small intesting (source- niacin as a drug repositioning candidate for hyperphos mgmt. in dialysis patients- Therapeutics and Clinical Risk mgmt. 2014)
Historical use:
Dietary sources: proteins, organ meats, grain products (
Lowers LDL 5-20 mg/dL
Increases HDL mg/dL
Lowers triglycerides mg/dL

15. Clinical Research into Niacin Use for Lipids14-15
AIM-HIGH (NEJM 2011)
HPS2-THRIVE (NEJM 2014)
Overview: 3,414 patients with LDL of~70 mg/dL with cardiovascular disease, low HDL, elevated TGs, and on a statin were randomized to receive extended-release niacin or placebo
Result: Study stopped early due to futility. No additional benefit of niacin
Safety Concerns: Higher number of ischemic strokes (no difference than placebo) than expected.
Overview: 25,673 patients on simvastatin 40mg randomized to receive niacin 2 grams (plus laropriprant for flushing) or placebo
Result: No difference in first major vascular event after median of 3.9 years
Safety Concerns: Increased risk of myopathy, worsened glucose control, and bleeding
****Phosphorus or CKD mentioned at all here?******
●The AIM-HIGH trial of 3414 patients with established cardiovascular disease, low HDL-C, elevated triglycerides, and treated with a statin (mean LDL-C of 70 mg/dL) found no additional benefit to treatment with extended-release niacin [37]. The study was stopped early for futility and because of a concern about increased numbers of ischemic strokes in patients treated with niacin, which were not significantly different from placebo after final adjudication. However, HDL-C levels in the "placebo" arm (which received 100 to 200 mg of niacin daily) increased more than expected, which may have reduced the ability of the trial to detect a real benefit with niacin therapy. (See "Management of low density lipoprotein cholesterol (LDL-C) in secondary prevention of cardiovascular disease".)
The AIM-HIGH trial does not answer the question of whether niacin would be of value in patients on statin therapy but much higher initial LDL-C levels.
●HPS2-THRIVE randomly assigned 25,673 adults ages 50 to 80 with vascular disease to receive extended–release niacin 2 grams daily plus laropiprant (to reduce flushing from niacin) or placebo; all patients received simvastatin 40 mg daily, and if LDL-C reduction was inadequate with simvastatin, ezetimibe 10 mg daily was added [38]. After a median follow-up of 3.9 years, there was no reduction with niacin/laropiprant in the primary end point of first major vascular event (13.2 versus 13.7 percent; risk ratio [RR] 0.96, 95% CI ) and there was also no benefit for this end point in the subgroup of patients with low HDL-C and elevated triglycerides. There was a statistically nonsignificant increase in mortality (6.2 versus 5.7 percent, RR 1.09, CI ). Additionally, and despite the run-in period, there was an increase in serious adverse events. These included myopathy (RR 3.54), but with a much greater increased risk in patients from study centers in China (RR 5.2) than in Europe (RR 1.5), gastrointestinal side effects, and rash. Niacin/laropiprant worsened glucose control with both an increase in new cases of diabetes (RR 1.32) and serious disturbance in diabetes control (11.5 versus 7.5 percent, RR 1.55; most of these led to hospitalization). Additionally, there were unanticipated increases in serious infections (8.0 versus 6.6 percent; RR 1.22, CI ) and bleeding (2.5 versus 1.9 percent; RR 1.38, CI ).
Niacin was administered with laropiprant in HPS2-THRIVE, and so it is not possible to completely sort out the effects that might have been due to laropiprant, particularly with regard to the unexpected findings of excess bleeding and infection. However, given the results of HPS2-THRIVE, infection and bleeding were subsequently analyzed in AIM-HIGH, which studied niacin without laropiprant [39]. Infections were increased with niacin (8.1 versus 5.8 percent; p = 0.008), and there were only small numbers to assess rates of bleeding (3.4 versus 2.9 percent; p = 0.36). This explanation for the observation of an increased infection risk is not known [40].
Citation: AIM-HIGH Investigators, Boden WE, Probstfield JL, et al. Niacin in patients with low HDL cholesterol levels receiving intensive statin therapy. N Engl J Med 2011; 365:2255.
HPS2-THRIVE Collaborative Group, Landray MJ, Haynes R, et al. Effects of extended-release niacin with laropiprant in high-risk patients. N Engl J Med 2014; 371:203.

16. Niacin and Phosphorus control16-20
Niacin is bioconverted to nicotinamide adenine dinucleotide (NAD+) and the hydride equivalent (NADH)
Coenzymes necessary for tissues metabolism, lipid metabolism, and glycogenolysis
Package insert for Niaspan® states its use has been associated with small but statistically significant reductions in phosphorus levels
Mean of -13% with 2000mg daily
50% of phosphorus absorption occurs in the duodenum and jejunum through active transport involving Type IIb sodium- phosphate cotransporters
Animal studies have shown nicotinamide inhibiting the expression of these transporters
Citation (via renal nutrition forum citations)

17. Blood
Phosphate
Phosphate Binder
Enterocyte
Lumen
Effect of niacin

18. Quiz Break! Niacin works to reduce phosphorus by:
Binding to phosphate leading to excretion of an insoluble complex
Inhibiting the Type IIb- Sodium co-transporter, responsible for phosphorus absorption
Increasing the excretion by blocking receptors in the ascending loop of Henle
Acting as an enzyme to facilitate the breakdown of phosphate products into poorly absorbed by-products
Answer A we have the MOA of our phosphate binders. C and D we have non-sense answers of my own creation.

19. Association of Niacin on Phosphate Control in Advanced-Stage Chronic Kidney Disease Patients within a VA Population21
McArdle KM, Burge NJ, Kim S, et al. Association of niacin on phosphate control in advanced-stage chronic kidney disease patients within a va population. Renal nutrition forum (2):8-12.

20. Overview of our Study
Retrospective, case-control study of phosphorus control between patient groups
Matched patients between groups to level of kidney impairment
Dates of eligibility included those from January 1, December 31, 2014
Add in citation from the Renal Journal Quarterly
Reason we looked for this, is that the ACC/AHA guidelines just came out in November 2013, studies have shown it often takes a few years for new guidelines to take effect, and upon review of patients I see, noting that many were still on niacin as continued maintenance therapy.

21. Outcomes measured Primary outcome Secondary outcomes
Phosphorus control
Median phosphorus level within each treatment group
Measured using each subject’s average serum phosphorus level over 6 months
Secondary outcomes
Pill burden
Sub-group Analysis
Diabetics
Concurrent aspirin use
History of consultation with a renal dietitian
Adherence with niacin
Primary outcomes/secondary outcomes
Inclusion/exclusion criteria
Results
Strengths
Weaknesses
Place in therapy

22. Admission Criteria Inclusion Criteria Exclusion Criteria
Adult, male patients
Diagnosis of CKD stage 4, 5, or ESRD
Actively followed within renal clinic at Hines VA
>3 phosphorus levels within 6 month time period
Niacin use in the treatment group for <6 months
New consult from renal dietitian
Initiation or discontinuation of dialysis
Admission into hospital or extended care center

23. Data Points Collected Primary endpoint Secondary endpoint
Serum phosphorus levels
Secondary endpoint
Use of phosphate binders
Subgroup analyses
A1c
Refill information for niacin
Dietitian consult
Aspirin use
Age
Race
CKD diagnosis
Etiology of kidney impairment
Duration of dialysis
Average SCr + eGFR
Serum albumin
Calcium levels
Average PTH
Vitamin D analogs or calcimimetics
Other medications that may ↓ phosphorus
Documented allergy to niacin

24. Patient Breakdown Patients with CKD Niacin Eligible Sample Control
5430
Niacin
531
Eligible Sample 25
Control
4899
Matched Sample

25. Baseline Characteristics
Niacin Group
n = 25
Control Group
P-value
Average Age
(years) 72 74
0.38
Race
(% of patients)
White: 84
Non-white or unknown: 16
White: 56
Non-white or unknown: 44
0.10
Etiology of Kidney Impairment
(% of patients)
Diabetes: 48
Hypertension: 8
Multifactorial: 40
Other/unknown: 4
Diabetes: 52
Hypertension: 12
Multifactorial: 24
Other/unknown: 12
0.46

26. Baseline Characteristics- Cont’d
Niacin Group
n = 25
Control Group
P-value
Level of Kidney Impairment
(% of patients)
CKD stage 4: 18 (72%)
CKD stage 5: 3 (12%)
ESRD: 4
(16%)
Groups were matched for this characteristic
Average SCr
(mg/dL)
3.6
0.33
Average eGFR
(mL/min) 21 18
0.07
Average Duration of Dialysis if ESRD
(years)
3.75
2.25
0.32

27. Primary and Secondary Outcomes
Niacin Group
n = 25
Control Group
P-Value
Median Serum Phosphorus Level
(mg/dL)
3.5
4.2
0.0003
Niacin Group
n = 25
Control Group
P-Value
Average Phosphorus >4.6 mg/dL
(# of patients) 2 6
0.13
Use of Phosphate Binders 5
0.23
Average Daily Dose of Phosphate Binders
(# of tablets)
3.5
5.8
0.39

28. Average Corrected Calcium
Other Results
Niacin Group
n = 25
Control Group
P-value
Average Corrected Calcium
(mg/dL)
9.40
9.37
0.84
Average A1c
(%)
7.5
0.88

29. Other Results 7 5

30. Niacin Group Results- Adherence and New Starts
Average Medication Possession Ratio (MPR) = 0.78
% of patients with:
MPR >0.8 – 56%
Concurrent aspirin therapy – 96%
Documented allergy to niacin – 4%
Pre/Post- Niacin Initiation Analysis:
4 patients started niacin within the data collection period
Mean change in phosphorus after 6 months = ↓ 0.9 mg/dL
Define Medication Possession Ratio

31. Niacin Group Results- Cont’d

32. Conclusions Statistical difference found in phosphorus control
Niacin was associated with clinically significant lower phosphate levels
Similar findings when assessing patients adherent with niacin
Correlation was not found between niacin dose and phosphorus level
Average daily dose of phosphate binders: 3.5 tablets (niacin) vs tablets (control)

33. Discussion Strengths Weaknesses
Controlled for outliers in phosphorus level by comparing median levels
Assessed use of phosphate binders as secondary endpoint
Not seen in prior studies
Evaluated safety
A1c, allergies, aspirin use
Retrospective design
Did not meet pre-specified enrollment
Only 56% of patients were adherent with niacin based on MPR
Many patients do not start phosphate binders until after dialysis initiated
****Need to know pre-specified enrollment goals

34. Conclusions
Results from this study support the use of niacin in hyperphosphatemia treatment in patients with advanced-stage kidney disease
There is a need for randomized controlled trials to better assess the effect of niacin on phosphorus levels

35. Are There Randomized Controlled Trials for Niacin Use?
Comparison of Efficacy of the Phosphate Binders Nicotinic Acid and Sevelamer Hydrochloride in Hemodialysis Patients
Ahmadi F, Shamekhi F, Lessan-Pezeshki M, Khatami MR. Saudi Journal of Kidney Disease/Transplantation. 2012; 23(5):
Niacin Lowers Serum Phosphate and Increases HDL Cholesterol in Dialysis Patients
Muller D, Mehling H, Otto B, et al. Clin J Am Soc Nephrol. 2007; 2:
Hypophosphatemic Effect of Niacin in Patients Without Renal Failure: A Randomized Trial
Maccubbin D, Tipping D, Kuznetsova O, et al. Clin J Am Soc Nephrol. 2010; 5:
Mention ongoing study from Northwestern Univeristy aiming to examine lanthanum/niacinamide

36. Overview of Other Studies Examining Niacin Usage22-24
Nicotinic Acid 1500mg po qAM/1000mg po qPM vs. sevelamer 1600mg twice daily. Total of 40 patients
Niacin Group: 7.3 → 5.6 mg/dL; Sevelamer: 6.9 → 4.7 mg/dL
Ahmadi F,
et al. (2012)
Prospective study of 20 HD patients on extended-release niacin
↓ Phosphate levels from 7.2 to 5.9 mg/dL (p= 0.015)
Muller D,
et al. (2007)
Post-hoc analysis of 1609 patients with SCr < 1.7 mg/dL. Niacin extended-release 1000mg or placebo
11% decrease in phosphorus (0.4 mg/dL vs. baseline)
Maccubbin D,
et al. (2010)

37. Quiz Break!
Compared to other published trials, our results showed a/an:
Similar association of lower phosphorus levels
Improved phosphorus control compared to phosphate binders
Similar reduction in prescribed # of phosphate binders
A higher rate of adverse events
Answer A
No comparison of phos bidners, just associatated phos levels
C  That is somewhat uique without our trial, looking at pill burden
D Very little I adverse events… largely due to selection bias as a retrospective study

38. Evaluation of a New Therapy Compared to Current Options
Is it more/equally effective?
Is it easier to take (smaller tablet; less times per day)?
Does it save lives/Does it save money?
Is it better tolerated? Are there less side effects?
As a clinical pharmacist, we are trained to examine one thing with a new agent- is it more/equally effective as other options (Similar from lmited trials)? Is it better tolerated (Few issues that we will discuss shortly, but little from trials to be concerning? Is it easier to take (Resounding yes here, due to different MOA? Does it save money/lives (Not often the case with new drugs since they are branded… in this case certainly so?
Available OTC
Inexpensive
Limited data but effective

39. Where Should Niacin Fit?
More/Equally Effective?
-Limited studies, but similar reductions in phosphorus seen
Easier to Take?
-Once daily/Without regard to meals
Does it Save Lives/Money?
-No mortality benefit seen with either agents
-Significant Cost Savings ($0.30/day)
Is it Better Tolerated? Less Side Effects?
???
As a clinical pharmacist, we are trained to examine one thing with a new agent- is it more/equally effective as other options (Similar from lmited trials)? Is it better tolerated (Few issues that we will discuss shortly, but little from trials to be concerning? Is it easier to take (Resounding yes here, due to different MOA? Does it save money/lives (Not often the case with new drugs since they are branded… in this case certainly so?
****Check marks here?****
Available OTC
Inexpensive
Limited data but effective

40. Safety Concerns with Niacin17
Multiple Warnings/Precautions
Gastrointestinal Effects
Hepatotoxicity
Diabetes
Gout
Flushing/Pruritus
Lexi-Comp
“This is not an option for everone”

41. GI Issues Warning/Precautions Data Concern for patients?
May cause GI distress or aggravate peptic ulcer disease
Data
Cause/effect relationship not established
Use of niacin contraindicated in patients with active peptic ulcer disease and used cautiously in those with a history of ulcers
Concern for patients?
Low threshold for holding if history of ulcers/GI bleeds

42. Hepatotoxicity Warning/Precautions Data Concern for patients?
Cases of severe hepatic toxicity, including fulminant hepatic necrosis, have occurred in patients who have substituted sustained- release niacin for immediate-release niacin at equivalent doses
Data
<1% (2/245) of patients receiving long-acting niacin had drug discontinued due to elevations in liver function tests
Concern for patients?
Liver function tests should be monitored every 6-12 weeks initially
Particular caution for those with a history of alcohol abuse or with a past history of liver disease

43. Diabetes Warning/Precautions Data Concern for patients?
May increase fasting blood glucose
Data
Increases are generally modest (<5%)
Concern for patients?
May require adjustment in diet and/or medication therapy
If ongoing persistent hyperglycemia, discontinue use

44. Gout Warning/Precautions Data Concern for patients?
Associated with hyperuricemia
Use with caution in those predisposed to gout
Data
Little available; thought to both increase production and reduce excretion of uric acid
Concern for patients?
Would advise against using in those on chronic preventative therapy for gout or with a recent flare

45. Flushing/Pruritus

46. Flushing/Pruritus Warning/Precautions Data
Causes release of Prostaglandin D2, leading to flushing, feeling of warmth, and pruritus
Data
Variable presentation, up to 80% with flushing per clinical trials. 20% with pruritus

47. Flushing/Pruritus Concern for patients?
Recommendations available for taking aspirin 325mg 30 minutes before dosing
Risk of aspirin 325mg?
Non-pharmacological means
Administer with food
Avoid taking with ethanol or any hot liquids
Avoid constricting clothing
Extended release preparations thought to have significantly less flushing than immediate release

48. Quiz Break! Patient Case
62 year old patient with ESRD on maintenance HD three times weekly. PMH of ESRD, HTN, dyslipidemia, gout, BPH, and gastric AV malformations requiring cauterization in 2014
Phos is elevated (6.3), patient is refusing dietary modification and that he often forgets phos binders when out of the house (most of his meals)
On dialysis rounds, you consider whether niacin would be an appropriate recommendation, you decide:
Yes it is a good option, improving phos control will improve this patient’s mortality risk
Yes it is a good option, this will help by offering an alternative mechanism of action to phosphate binders
No it is not a good option due to benefit of focus on diet modifications first
No it is not a good option due to his past medical history

49. Pill Burden, Adherence, Hyperphosphatemia, and Quality of Life in Maintenance Dialysis Patients11
Chiu Y, Teitelbaum, I, Misra M, et al. Pill burden, adherence, hyperphosphatemia, and quality of life in maintenance dialysis patients. Clinical Journal of the American Society Nephrology Jun;4(6): doi: / CJN Epub 2009 May 7.

50. Major Findings of Pill Burden and effects in HD Patients
Cross-sectional assessment of 233 dialysis patients from 3 geographically-different areas of the United States
Total Medication Number
11 +/- 4
Total Pill Burden
19 (12)

51. Strategies to Optimize Phos control
Dietary sources and dietary recall
Very important for dietary counseling
Timing of meds
Taking right before a meal or within 1-2 hours
Appropriate counseling
Importance of knowing meal schedule (large meals, snacks, etc.)
Definition of what a ‘snack’ is
Could certain phos binders reduce pill burden?
Ie- Lanthanum/sucroferric oxyhydroxide
Deitary sources- Often able to counsel patients that we have options, whether it be adjusting diet for some, or adjusting number of meds for others. One doesn’t mean you can ignore the other, but importance of following a patients wishes

52. Refill History and Adherence
Refill history from provided pharmacy
Calling their retail pharmacy to request how often they are refilling
Should we look for medication possession ratio of >80%?
30-Day supply  One tablet three times daily  90 tablets
Meal Schedule
How can refill history be used
Definition of snacking- is it an apple, is it 2 sandwiches, is it a sleeve of cookies?
Refill history Use it to at least ensure they are refilling. One refill in 10 months may indicate non-adherence: Whether it be cost, tolerability

53. Medications with phosphorus additives
There are certain meds that are more likely to have inactive ingredients with phosphorus additives
Studied sparingly, companies themselves have reported not having data on this
Niche population despite its importance…
Not many disease states where chronic phosphorus monitoring is needed

54. Overview
Niacin may have a role in helping control phosphorus levels in certain patients
Niacin works differently than our standard therapies
There can be significant risks with this medication
Monitoring pill burden and assessing adherence is very important to helping out patients

55. Questions?

56. References
Hudson JQ, Wazny LD. Hudson J.Q., Wazny L.D. Hudson, Joanna Q., and Lori D. Wazny.Chronic Kidney Disease. In: DiPiro JT, Talbert RL, Yee GC, Matzke GR, Wells BG, Posey L. DiPiro J.T., Talbert R.L., Yee G.C., Matzke G.R., Wells B.G., Posey L Eds. Joseph T. DiPiro, et al.eds. Pharmacotherapy: A Pathophysiologic Approach, 10e New York, NY: McGraw-Hill; . Accessed October 22, 2017.
Kestenbaum B, Sampson JN, Rudser KD, Patterson DJ, Seliger SL, Young B, Sherrard DJ, Andress DL. Serum phosphate levels and mortality risk among people with chronic kidney disease. J Am Soc Nephrol. 2005;16:520–528.
Block  GA, Klassen  PS, Lazarus  JM,  et al. Mineral metabolism, mortality and morbidity in maintenance hemodialysis. J Am Soc Nephrol 2004;15:2208–2218. Accessed: 24 September 2017.
Calcium Carbonate. Lexi-Drugs. Lexicomp. Wolters Kluwer Health, Inc. Riverwoods, IL.  Available at:  Accessed September 25, 2017.
Calcium Acetate. Lexi-Drugs. Lexicomp. Wolters Kluwer Health, Inc. Riverwoods, IL.  Available at:  Accessed September 25, 2017.
Sevelamer. Lexi-Drugs. Lexicomp. Wolters Kluwer Health, Inc. Riverwoods, IL.  Available at:  Accessed September 25, 2017.
Lanthanum. Lexi-Drugs. Lexicomp. Wolters Kluwer Health, Inc. Riverwoods, IL.  Available at:  Accessed September 25, 2017.
Ferric Citrate. Lexi-Drugs. Lexicomp. Wolters Kluwer Health, Inc. Riverwoods, IL.  Available at:  Accessed September 25, 2017.
Sucroferric Oxyhydroxide. Lexi-Drugs. Lexicomp. Wolters Kluwer Health, Inc. Riverwoods, IL.  Available at:  Accessed September 25, 2017.
Jamal SA, Vandermeer B, Raggi P, et al. Effect of calcium-based versus non-calcium-based phosphate binders on mortality in patients with chronic kidney disease: an updated systematic review and meta-analysis. Lancet. 2013; 382:
Chiu Y, Teitelbaum, I, Misra M, et al. Pill burden, adherence, hyperphosphatemia, and quality of life in maintenance dialysis patients. Clinical Journal of the American Society Nephrology. 2009

57. References-Continued
Chiu Y, Teitelbaum, I, Misra M, et al. Pill burden, adherence, hyperphosphatemia, and quality of life in maintenance dialysis patients. Clinical Journal of the American Society Nephrology Jun;4(6): doi: / CJN Epub 2009 May 7.
Dietitians of Canada. Food sources of niacin (vitamin B3). Available at: Z/Vitamins/Food-Sources-of-Niacin.aspx. Accessed October 18, 2017.
Talbert RL. Talbert R.L. Talbert, Robert L.Dyslipidemia. In: DiPiro JT, Talbert RL, Yee GC, Matzke GR, Wells BG, Posey L. DiPiro J.T., Talbert R.L., Yee G.C., Matzke G.R., Wells B.G., Posey L Eds. Joseph T. DiPiro, et al.eds. Pharmacotherapy: A Pathophysiologic Approach, 10e New York, NY: McGraw-Hill; . Accessed October 25, 2017.
AIM-HIGH Investigators, Boden WE, Probstfield JL, et al. Niacin in patients with low HDL cholesterol levels receiving intensive statin therapy. N Engl J Med 2011; 365:2255.
HPS2-THRIVE Collaborative Group, Landray MJ, Haynes R, et al. Effects of extended-release niacin with laropiprant in high-risk patients. N Engl J Med 2014; 371:203.
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