Using Al(OH)3 to treat hyperphosphatemia

For those clinicians who use Al(OH)3 to treat hyperphosphatemia, what is the dose that is prescribed to start, and how do you titrate? Here in the US, it can be difficult to obtain aluminum hydroxide, as it has to be made in a compound pharmacy and not all of them will do it. I have the best luck with being able to obtain oral suspension, but I have only ever experienced a couple of clinicians who are willing to prescribe it, and even then only for 2 weeks at a time. I have been practicing as a renal RD for 12 years and less than a handful of my pts have used it.

Here’s info on aluminum hydroxide from the PDR. I have worked in dialysis as a social worker since 1978. In those early days, aluminum hydroxide was commonly used as a phosphate binder. However, in recent years its use has declined because of the risk of neurotoxicity, bone disease, cognitive changes, etc. This description says this related to people with severe renal impairment. “CrCl < 10 mL/min: While aluminum hydroxide has been used historically in patients with ESRD as a dietary phosphate-binder, avoid use in renal failure due to the potential for aluminum accumulation. If aluminum hydroxide must be used, the dosage should be modified depending on clinical response and evidence of aluminum accumulation.” It doesn’t say what the dose should be after adjustment.

I’d hope that patient education and dietary (and psychosocial) counseling along with one of the new phosphate binders would result in improvement bone disease management without those risks association with aluminum hydroxide.