A strategy based on patient preference improves the adherence and outcomes of phosphate binders in hemodialysis


Phosphate binders (PB) have to be taken with food, their interference with an individual's lifestyle and social habits influences treatment adherence. Several PBs are available, and patient preferences should not be ignored when prescribing. The purpose was to know the extent of intentional and unintentional nonadherence to PB in hemodialysis (HD) patients, and to evaluate the long-term results (adherence, serum phosphate levels, and cost) of a strategy of prescription of PB that takes into account patient preferences.

A prospective open-label, single-arm study, conducted in all 130 prevalent HD patients of our unit. Each patient was compared with themselves before (baseline) and 6, 12, and 24 months after adopting the new strategy. Factors included in the decision tree to prescribe PB were patient preferences, cost, and security. Self-reported, intentional, and unintentional nonadherence, serum P levels, and cost were evaluated. Patients were instructed to request a change of PB if they had problems or did not like those prescribed. Results: After implementing the new strategy, the percentage of patients receiving calcium PB monotherapy increased (p < 0.001), while the percentage of those receiving noncalcium PB monotherapy (p < 0.001) and a combination of noncalcium PB (p < 0.01) decreased. Self-reported nonadherence (64.6%) and intentional nonadherence (38.4%) decreased significantly at 6 months and remained stable until the end of the study (50.6%; p < 0.05 and 24.9%; p < 0.01, respectively). Unintentional nonadherence did not change. Intentionally nonadherent patients at baseline showed a significant and maintained decrease of serum P levels (p < 0.05) and in the number of tablets/day of PB (p < 0.01). Implementing the protocol resulted in a significant reduction of costs expended in PB.

Individualization of treatment that takes into account patient preferences improves the adherence and control of P levels at a lower cost. The most important changes after the new strategy were observed in intentionally nonadherent patients.
.