Sucroferric oxyhydroxide

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Sucroferric oxyhydroxide
Clinical data
Trade names Velphoro
AHFS/ Consumer Drug Information
License data
  • US: B (No risk in non-human studies)
  • EU, Japan: No risk in non-human studies
Routes of
Oral (chewable tablets)
ATC code
Legal status
Legal status
  • US: ℞-only
  • EU: Rx only
  • Japan: prescription only
Chemical and physical data
Formula Varies

Sucroferric oxyhydroxide (INN; trade name Velphoro, by Vifor Fresenius Medical Care Renal Pharma) is a non-calcium, iron-based phosphate binder used for the control of serum phosphorus levels in adult patients with chronic kidney disease (CKD) on haemodialysis (HD) or peritoneal dialysis (PD).[1] It is used in form of chewable tablets.


In a healthy person, normal serum phosphate levels are maintained by the regulation of dietary absorption, bone formation and resorption, equilibration with intracellular stores, and renal excretion.[2] When kidney function is impaired, phosphate excretion declines. Without specific treatment, hyperphosphataemia occurs almost universally, despite dietary phosphate restriction and conventional dialysis treatment.[2][3] In patients on dialysis, hyperphosphataemia is an independent risk factor for fractures, cardiovascular disease and mortality.[4][5] Abnormalities in phosphate metabolism such as hyperphosphatemia are included in the definition of the new chronic kidney disease–mineral and bone disorder (CKD-MBD).[5]

Structure and mechanism of action[edit]

Sucroferric oxyhydroxide comprises a polynuclear iron(III)-oxyhydroxide core that is stabilised with a carbohydrate shell composed of sucrose and starch.[6][7] The carbohydrate shell stabilises the iron(III)-oxyhydroxide core to preserve the phosphate adsorption capacity.

Dietary phosphate binds strongly to sucroferric oxyhydroxide in the gastrointestinal (GI) tract. The bound phosphate is eliminated in the faeces and thereby prevented from absorption into the blood. As a consequence of the decreased dietary phosphate absorption, serum phosphorus concentrations are reduced.

Medical uses[edit]

Sucroferric oxyhydroxide is approved by the United States Food and Drug Administration (FDA) and the European Medicines Agency (EMA) for the control of serum phosphorus levels in patients with chronic kidney disease (CKD) on dialysis.[1][8]

Adverse effects[edit]

The most frequently reported adverse drug reactions reported from trials were diarrhoea and discoloured faeces.[1][8] The vast majority of gastrointestinal adverse events occurred early during treatment and abated with time under continued dosing.[1]


Drug-interaction studies and post hoc analyses of Phase 3 studies showed no clinically relevant interaction of sucroferric oxyhydroxide with the systemic exposures to losartan, furosemide, omeprazole, digoxin, and warfarin,[9] the lipid-lowering effects of statins,[10] and oral vitamin D receptor agonists.[11] According to the European label (Summary of Product Characteristics), medicinal products that are known to interact with iron (e.g. doxycycline) or have the potential to interact with Velphoro should be administered at least one hour before or two hours after Velphoro.[1] This allows sucroferric oxyhydroxide to bind phosphate as intended and be excreted without coming into contact with medications in the gut that it might interact with. According to the US prescribing information, Velphoro should not be prescribed with oral levothyroxine.[8] The combination of sucroferric oxyhydroxide and levothyroxine is contraindicated because sucroferric oxyhydroxide contains iron, which may cause levothyroxine to become insoluble in the gut, thereby preventing the intestinal absorption of levothyroxine.[12]


The chewability of sucroferric oxyhydroxide compares well with that of Calcimagon, a calcium containing tablet used as a standard for very good chewability.[13] Tablets of sucroferric oxyhydroxide easily disintegrated in artificial saliva.

Effectiveness and phosphate binding[edit]

Clinical Phase 3 studies showed that sucroferric oxyhydroxide achieves and maintains phosphate levels in compliance with the KDOQI guidelines.[14][15] The reduction in serum phosphate levels of sucroferric oxyhydroxide-treated patients was non-inferior to that in sevelamer-treated patients. The required daily pill burden was lower with sucroferric oxyhydroxide.[14]

Sucroferric oxyhydroxide binds phosphate under empty and full stomach conditions and across the physiologically relevant pH range of the GI tract.[7]

In a retrospective, real-world study, hyperphosphatemic peritoneal dialysis patients who were prescribed to switch to sucroferric oxyhydroxide from sevelamer, lanthanum carbonate, or calcium acetate had significant reductions in serum phosphorus levels, along with a 53% decrease in the prescribed daily pill burden.[16]


  1. ^ a b c d e "Velphoro (sucroferric oxyhydroxide). Summary of Product Characteristics" (PDF). EMA. Archived from the original on October 21, 2014. Retrieved 24 October 2014. 
  2. ^ a b Jha V, Garcia-Garcia G, Iseki K, Li Z, Naicker S, Plattner B, Saran R, Wang AY, Yang CW (July 2013). "Chronic kidney disease: global dimension and perspectives". Lancet. 382 (9888): 260–72. doi:10.1016/S0140-6736(13)60687-X. PMID 23727169. 
  3. ^ Hutchison AJ, Smith CP, Brenchley PE (September 2011). "Pharmacology, efficacy and safety of oral phosphate binders". Nature Reviews. Nephrology. 7 (10): 578–89. doi:10.1038/nrneph.2011.112. PMID 21894188. 
  4. ^ Isakova T, Gutiérrez OM, Chang Y, Shah A, Tamez H, Smith K, Thadhani R, Wolf M (February 2009). "Phosphorus binders and survival on hemodialysis". Journal of the American Society of Nephrology. 20 (2): 388–96. doi:10.1681/ASN.2008060609. PMC 2637053Freely accessible. PMID 19092121. 
  5. ^ a b "KDIGO clinical practice guideline for the diagnosis, evaluation, prevention, and treatment of Chronic Kidney Disease-Mineral and Bone Disorder (CKD-MBD)". Kidney International Supplement. 76 (113): S1–130. August 2009. doi:10.1038/ki.2009.188. PMID 19644521. 
  6. ^ Vifor Fresenius Medical Care Renal Pharma. Product Monograph 2015.
  7. ^ a b Wilhelm M, Gaillard S, Rakov V, Funk F (April 2014). "The iron-based phosphate binder PA21 has potent phosphate binding capacity and minimal iron release across a physiological pH range in vitro". Clinical Nephrology. 81 (4): 251–8. doi:10.5414/cn108119. PMID 24656315. 
  8. ^ a b c "Highlights of Prescribing information for Velphoro". Fresenius. September 2014. 
  9. ^ Chong E, Kalia V, Willsie S, Winkle P (December 2014). "Drug-drug interactions between sucroferric oxyhydroxide and losartan, furosemide, omeprazole, digoxin and warfarin in healthy subjects". Journal of Nephrology. 27 (6): 659–66. doi:10.1007/s40620-014-0080-1. PMC 4242982Freely accessible. PMID 24699894. 
  10. ^ Levesque V, Chong EMF, Moneuse P (2013). "Post-hoc analysis of pharmacodynamic interaction of PA21 with statins in a Phase 3 study of PA21 in dialysis patients with hyperphosphatemia". J Am Soc Nephrol. 24: 758A. 
  11. ^ Floege J, Botha J, Chong E et al. (31 May 2014). PA21 does not interact with oral vitamin D receptor agonists: a post hoc analysis of a Phase 3 study. ERA-EDTA congress. Amsterdam, The Netherlands. Abstract no. SP257. 
  12. ^ Prescribing Information. Synthroid (levothyroxine). Chicago, IL: Abbott Laboratories. March 1, 2008. 
  13. ^ Lanz M, Baldischweiler J, Kriwet B, Schill J, Stafford J, Imanidis G (December 2014). "Chewability testing in the development of a chewable tablet for hyperphosphatemia". Drug Development and Industrial Pharmacy. 40 (12): 1623–31. doi:10.3109/03639045.2013.838583. PMID 24010939. 
  14. ^ a b Floege J, Covic AC, Ketteler M, Rastogi A, Chong EM, Gaillard S, Lisk LJ, Sprague SM (September 2014). "A phase III study of the efficacy and safety of a novel iron-based phosphate binder in dialysis patients". Kidney International. 86 (3): 638–47. doi:10.1038/ki.2014.58. PMC 4150998Freely accessible. PMID 24646861. 
  15. ^ Floege J, Covic AC, Ketteler M, Mann JF, Rastogi A, Spinowitz B, Chong EM, Gaillard S, Lisk LJ, Sprague SM (June 2015). "Long-term effects of the iron-based phosphate binder, sucroferric oxyhydroxide, in dialysis patients". Nephrology, Dialysis, Transplantation. 30 (6): 1037–46. doi:10.1093/ndt/gfv006. PMC 4438742Freely accessible. PMID 25691681. 
  16. ^ Kalantar-Zadeh K, Parameswaran V, Ficociello LH, Anderson L, Ofsthun NJ, Kwoh C, Mullon C, Kossmann RJ, Coyne DW (2018). "Real-World Scenario Improvements in Serum Phosphorus Levels and Pill Burden in Peritoneal Dialysis Patients Treated with Sucroferric Oxyhydroxide". American Journal of Nephrology. 47 (3): 153–161. doi:10.1159/000487856. PMC 5906196Freely accessible. PMID 29514139.