Note: Use in combination with dietary phosphate restriction (Ref).
Hyperphosphatemia in chronic kidney disease, treatment:
Oral: Initial: 1,500 mg/day in divided doses taken with or immediately after meals.
Dosage adjustment: Increase or decrease dose by 250 or 500 mg per meal at 2- to 3-week intervals as needed to obtain targeted serum phosphorus concentrations; usual dosage range: 1,500 to 3,000 mg/day in divided doses (Ref).
Dosage adjustment for concomitant therapy: Significant drug interactions exist, requiring dose/frequency adjustment or avoidance. Consult drug interactions database for more information.
No dosage adjustment necessary.
There are no dosage adjustments provided in the manufacturer's labeling.
Refer to adult dosing.
The following adverse drug reactions and incidences are derived from product labeling unless otherwise specified.
>10%:
Gastrointestinal: Diarrhea (oral powder: ≤18%; chewable tablets: ≤7%), nausea (oral powder: ≤18%; chewable tablet: ≤11%), vomiting (oral powder: ≤18%; chewable tablets: ≤9%)
1% to 10%:
Endocrine & metabolic: Hypocalcemia (5%)
Gastrointestinal: Abdominal pain (chewable tablet: 5%)
<1%, postmarketing, and/or case reports: Accidental injury (tooth injury with chewable tablets), allergic skin reaction, constipation, dyspepsia, fecal impaction, gastrointestinal perforation, hypophosphatemia, intestinal obstruction (including ileus and subileus), intestinal perforation
Bowel obstruction, fecal impaction, ileus
Canadian labeling: Additional contraindications (not in US labeling): Hypersensitivity to lanthanum carbonate or any component of the formulation; hypophosphatemia
Concerns related to adverse effects:
• GI obstruction: Serious GI obstruction, ileus, subileus, GI perforation, and fecal impaction have been reported, some requiring surgery or hospitalization. Risk factors include patients with altered GI anatomy (eg, diverticular disease, peritonitis, history of GI surgery, GI cancer, GI ulceration), hypomotility disorders (eg, constipation, ileus, subileus, diabetic gastroparesis), or medications known to potentiate effects; may also occur in patients without history of GI disease. Monitor patients closely for GI symptoms (eg, constipation, abdominal pain, abdominal distention); consider discontinuation in patients with unexplained severe GI symptoms.
Disease-related concerns:
• Biliary obstruction: Use with caution in patients with biliary obstruction (elimination of lanthanum may be reduced in these patients).
• Gastrointestinal disease: Use with caution in patients with active peptic ulcer, ulcerative colitis, or Crohn disease.
• Hepatic impairment: Use with caution in patients with hepatic impairment (elimination of lanthanum may be reduced in these patients).
Dosage form specific issues:
• Tablet: Chew thoroughly to decrease risk of serious adverse GI effects; do not swallow whole.
Other warnings/precautions:
• Abdominal x-rays: Lanthanum has radio-opaque properties; may appear as an imaging agent on abdominal x-ray. Product residue has been reported during endoscopic imaging.
• Bone deposition: Rising lanthanum levels were observed in bone biopsies of patients treated for up to 4.5 years. Lanthanum deposits into developing bone, including growth plates; consequences on developing bone are not known. Use in children is not recommended.
Excipient information presented when available (limited, particularly for generics); consult specific product labeling.
Packet, Oral:
Fosrenol: 750 mg (10 ea, 90 ea); 1000 mg (10 ea, 90 ea)
Tablet Chewable, Oral:
Fosrenol: 500 mg, 750 mg, 1000 mg
Generic: 500 mg, 750 mg, 1000 mg
May be product dependent
Chewable (Fosrenol Oral)
500 mg (per each): $14.41
750 mg (per each): $14.41
1000 mg (per each): $14.41
Chewable (Lanthanum Carbonate Oral)
500 mg (per each): $3.96 - $13.69
750 mg (per each): $4.50 - $13.69
1000 mg (per each): $4.06 - $13.69
Pack (Fosrenol Oral)
750 mg (per each): $14.41
1000 mg (per each): $14.41
Disclaimer: A representative AWP (Average Wholesale Price) price or price range is provided as reference price only. A range is provided when more than one manufacturer's AWP price is available and uses the low and high price reported by the manufacturers to determine the range. The pricing data should be used for benchmarking purposes only, and as such should not be used alone to set or adjudicate any prices for reimbursement or purchasing functions or considered to be an exact price for a single product and/or manufacturer. Medi-Span expressly disclaims all warranties of any kind or nature, whether express or implied, and assumes no liability with respect to accuracy of price or price range data published in its solutions. In no event shall Medi-Span be liable for special, indirect, incidental, or consequential damages arising from use of price or price range data. Pricing data is updated monthly.
Excipient information presented when available (limited, particularly for generics); consult specific product labeling. [DSC] = Discontinued product
Tablet Chewable, Oral:
Fosrenol: 250 mg [DSC], 500 mg, 750 mg, 1000 mg
Generic: 250 mg, 500 mg, 750 mg, 1000 mg
Administer with or immediately after meals. Consider separating administration of oral medications from lanthanum when reduced bioavailability would significantly affect the concomitant medication's safety or efficacy; duration of separation varies based on absorption characteristics and whether it is an IR or ER product; monitor clinical response and/or blood concentrations of concomitant medications with a narrow therapeutic range.
Chewable tablet: Tablet should be chewed completely prior to swallowing; do not swallow whole. Tablet may be crushed to aid in chewing. Unchewed or incompletely chewed tablets may cause serious GI complications.
Oral powder: Sprinkle powder on a small quantity of applesauce or other similar food (not liquid) and administer immediately. Do not store for future use.
An FDA-approved patient medication guide, which is available with the product information and as follows, must be dispensed with this medication:
Fosrenol: https://www.accessdata.fda.gov/drugsatfda_docs/label/2023/021468s024,204734s006lbl.pdf#page=12
Hyperphosphatemia in chronic kidney disease, treatment: Reduction of serum phosphate in patients with end-stage kidney disease.
Lanthanum may be confused with lithium.
None known.
Note: Interacting drugs may not be individually listed below if they are part of a group interaction (eg, individual drugs within “CYP3A4 Inducers [Strong]” are NOT listed). For a complete list of drug interactions by individual drug name and detailed management recommendations, use the Lexicomp drug interactions program by clicking on the “Launch drug interactions program” link above.
Ampicillin: Lanthanum may decrease the serum concentration of Ampicillin. Management: Administer oral ampicillin at least two hours before or after lanthanum. Risk D: Consider therapy modification
Angiotensin-Converting Enzyme Inhibitors: Lanthanum may decrease the serum concentration of Angiotensin-Converting Enzyme Inhibitors. Management: Administer angiotensin-converting enzyme (ACE) inhibitors at least two hours before or after lanthanum. Risk D: Consider therapy modification
Antacids: May diminish the therapeutic effect of Lanthanum. Management: Administer antacid products at least 2 hours before or after lanthanum. Risk D: Consider therapy modification
Bacampicillin: Lanthanum may decrease the serum concentration of Bacampicillin. Management: Administer bacampicillin at least 2 hours before or after lanthanum. Risk D: Consider therapy modification
Chloroquine: Lanthanum may decrease the serum concentration of Chloroquine. Management: Administer chloroquine at least two hours before or after lanthanum. Risk D: Consider therapy modification
Halofantrine: Lanthanum may decrease the serum concentration of Halofantrine. Management: Administer halofantrine at least two hours before or after lanthanum. Risk D: Consider therapy modification
HMG-CoA Reductase Inhibitors (Statins): Lanthanum may decrease the serum concentration of HMG-CoA Reductase Inhibitors (Statins). Management: Administer HMG-CoA reductase inhibitors (eg, statins) at least two hours before or after lanthanum. Risk D: Consider therapy modification
Quinolones: Lanthanum may decrease the serum concentration of Quinolones. Management: Administer oral quinolone antibiotics at least one hour before or four hours after lanthanum. Risk D: Consider therapy modification
Tetracyclines: Lanthanum may decrease the serum concentration of Tetracyclines. Management: Administer oral tetracycline antibiotics at least 2 hours before or after lanthanum. Risk D: Consider therapy modification
Thyroid Products: Lanthanum may decrease the serum concentration of Thyroid Products. Management: Separate the administration of thyroid products and lanthanum by at least 4 hours. Risk D: Consider therapy modification
Environmental studies suggest lanthanum may cross the placenta (Huo 2017).
If a reduction of serum phosphate is needed in pregnant patients with end-stage renal disease, agents other than lanthanum are preferred. Discontinuation of phosphate binders may be required in patients on intensified hemodialysis during pregnancy (Burgner 2019; Hladunewich 2016; Tangren 2018; Wiles 2019).
It is not known if lanthanum is present in breast milk.
According to the manufacturer, use of a non-lanthanum phosphate binder is recommended in patients who are breastfeeding.
Take with or immediately after meals.
Serum calcium, phosphorus, and parathyroid hormone (PTH): Frequency of measurement may be dependent upon the presence and magnitude of abnormalities, the rate of progression of chronic kidney disease (CKD), and the use of treatments for chronic kidney disease-mineral and bone disorder (CKD-MBD) (KDIGO 2017):
CKD stage G3a to G3b: Serum calcium and phosphate: Every 6 to 12 months; PTH: Frequency based on baseline level and progression of CKD
CKD stage G4: Serum calcium and phosphate: Every 3 to 6 months; PTH: Every 6 to 12 months
CKD stage G5 and G5D: Serum calcium and phosphate: Every 1 to 3 months; PTH: Every 3 to 6 months
Note: Due to the complexity and interdependency of the laboratory parameters used for therapeutic decisions in chronic kidney disease-mineral and bone disorder (CKD-MBD) patients, serial assessments of phosphate, calcium, and parathyroid hormone (PTH) levels should be considered together (KDIGO 2017).
Calcium (total): Normal range: Adults: 8.5 to 10.5 m/dL (2.12 to 2.62 mmol/L) (IOM 2011). Avoid hypercalcemia for chronic kidney disease (CKD) stages G3a to G5D (KDIGO 2017).
Phosphorus: 2.5 to 4.5 mg/dL (0.81 to 1.45 mmol/L). Lower elevated phosphorus levels toward the normal range for CKD stages G3a to G5D (KDIGO 2017).
PTH:
CKD stage G3a to G5: Optimal PTH level is unknown; evaluate patients with progressively elevated intact PTH levels or if levels are consistently above the normal range (assay-dependent) (KDIGO 2017).
Dialysis patients: Maintain intact parathyroid hormone (iPTH) within 2 to 9 times the upper limit of normal for the assay used (KDIGO 2017).
Disassociates in the upper gastrointestinal tract to lanthanum ions (La3+) which bind to dietary phosphate resulting in insoluble lanthanum phosphate complexes and a net decrease in serum phosphate and calcium levels.
Absorption: <0.002%
Protein binding: >99%
Metabolism: Not metabolized
Half-life elimination: Plasma: 53 hours; Bone: 2-3.6 years
Excretion: Feces primarily; urine <2%
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