1. Conclusion and Future Direction:
Deprescribing Calcium-Based Phosphorus Binders in Dialysis Patients at University of Iowa Hospitals and Clinics
Aaron Schmitz, Kelsey Coffman, Michael Russell
 Dr. Michelle Fravel, PharmD, BCPS
Background: 
Chronic kidney disease complications
Mineral and bone disorder: Imbalance between phosphorus, calcium, parathyroid, vitamin D
Hyperphosphatemia has been linked to 
A reduction in alpha-1-hydroxylase activity causing decreased active vitamin D levels
An increase in parathyroid hormone 
These effects cause increased CV mortality, morbidity, and all-cause mortality
Maintaining normal phosphorus levels is a priority
Current treatments to maintain phosphorus levels are dietary restriction, dialysis, and medication therapy
Medication therapy options
Calcium carbonate and calcium acetate
Sevelamer HCl (Renagel) and sevelamer carbonate (Renvela)
Lanthanum (Fosrenol)
2 new iron-based: Auryxia and Velphoro
Calcium-based binders are more commonly used due to affordability, ease of use, and tolerability
Worse cardiovascular outcomes associated with use of calcium-based binders vs. Non-calcium based binders in clinical trials 
Kidney Disease: Improving Global Outcomes (KDIGO Guidelines) were updated in 2017 for bone and mineral disorders
Current Recommendation (2017): Restrict the dose of calcium-based phosphorus binders in all adult patients with CKD G3a-G5D (2B)
Previous Recommendation (2009): Restrict only in adults with hypercalcemia with CKD G3a-G5D (1B)
Objectives:
Describe the current prescribing patterns of calcium-based phosphate binders in patients receiving dialysis at the UIHC Dialysis Unit
Explore the opportunity to minimize the exposure to calcium-based phosphorus binders
Work with physicians to deprescribe calcium-based phosphorus binders
Results:
Results:
Results:
Of those taking calcium-based binder monotherapy, 13.6% (n=3) had low phosphorous levels, making them candidates for switching to a non-calcium based binder or decreasing the calcium dose
Of the 22 patients on calcium-based binders, up to 77.3% (n=17) would be eligible for intervention
Methods:
We reviewed the charts of 46 patients receiving dialysis at University of Iowa Hospitals and Clinics who were currently taking a phosphate binder
Patient demographics, phosphate binding therapy, and lab values were collected
Patients were categorized based on their phosphate binding therapy into treatment categories: 
Calcium-based binding therapy, sevelamer binding therapy sevelamer + calcium-based binding therapy (dual therapy)
We analyzed each phosphate binder therapy category for patterns related the patient demographics including age and gender 
If patients had been on alternative phosphate binder therapy previously we examined factors related to the switch including: 
What the reason for the switch was (adverse events, changes in lab values, etc.) 
If the switch occurred before or after the KDIGO guideline update 
We analyzed calcium and phosphorus control using the average of 3 lab values for each treatment category 
Correct calcium levels were calculated 
Of the 46 patients in our group, 27 (58.7%) were taking calcium-based monotherapy or dual therapy, making them eligible for intervention
Conclusion and Future Direction:
Non-calcium-based phosphorus binders are preferred in chronic kidney disease
Possible intervention groups for patients currently on calcium-based binders include patients with:
Normal or high calcium levels (switch to non-calcium based binder)
Low phosphorus levels  (decrease dose or d/c calcium-based binder)
In the future: work with physicians to deprescribe calcium-based phosphorus binders where appropriate
Evaluate the effect of deprescribing efforts  
References: 
1. CKD-Mineral and Bone Disorder (CKD-MBD).” KDIGO, 21 June 2017 
2. Di Lorio, Biagio. Sevelamer Versus Calcium Carbonate in Incident Hemodialysis Patients: Results of an Open-Label 24-month Randomized Clinical Trial Pubmed, AJKD, 20 May 2013
Of those taking calcium-based binder monotherapy, 63.6% (n=14) had normal/high calcium levels, making them candidates for switching to a non-calcium based binder