Scooter's Supplies for Chronic Renal Failure (CRF)

About Phosphorus Binders

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Phosphorus binders are a critical treatment for extending a CRF cat's life.  A 2001 study by Peter Markewell (BSc, BVetMed, MRCVS) for the Waltham Centre for Pet Nutrition found that "...using a phosphate- and protein-restricted diet, in combination with oral phosphorus-binding agents in those cats in which control of hyperphosphatemia [high phosphorus] and RHPTH [renal secondary hyperparathyroidism] was not achieved by diet alone, resulted in more than doubling of average survival time from the commencement of treatment." 

Both aluminum and calcium-based binders are available without prescription, but the aluminum based binders are more effective, safer, and often cheaper.  Renagel is an expensive prescription binder used only if cats cannot tolerate the aluminum and calcium binders.  Veterinarians report that "compliance rates" with phosphorus binders are low because owners have problems giving them and cats resist taking them.  Choose a binder that you're able to give and that is palatable to your cat.  Dried gel powders are mixed with an animal's wet and dry food.  Liquid suspensions are usually syringed onto a cat's tongue.  Both powders and liquids can also be given in gel caps but large dosages sometimes preclude this.  Binders must given with each meal so that they can bind with the phosphorus in newly consumed food and prevent its absorption into the body and bloodstream.  This page lists popular binders and places to buy them.

David's advice:  "Generic Aluminum Hydroxide Dried Gel USP powder" is the most effective, easiest to use and least expensive binder in almost every case.  Many vets are unaware that this over-the-counter (OTC) product is readily available from compounding pharmacies and via mail order, so you may have to educate them."
 

Information and Vendors


 
 
 
 
 

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Generic Aluminum Hydroxide Dried Gel Powder (Al(OH)3)


Generic Aluminum Hydroxide Dry Gel Powder (USP) may be purchased from local compounding or hospital pharmacies or via mail order.  This is the most convenient binder product because it is tasteless and easy to mix with wet food and even dry food (mix binder and dry food in a plastic baggie and dry food will absorb the binder overnight or slightly warm the dry food in the microwave (5-8 seconds) and then shake the powder with the food in a baggie like shake and bake ... the outer fatty coating of dry food (called digest) softens with warming and will let the powder attach more readily.). The dry gel powder is non-prescriptive but some compounding pharmacies and other vendors may insist upon a veterinary prescription. (Vets may know about liquid-based binders such as Alternagel but many are unaware of the generic aluminum hydroxide gel powder.)  For a cat that's going to be on binders for the rest of his or her life, this is most effective and least expensive option.  Three brands of aluminum hydroxide dry gel powder are readily available (PCCA, Spectrum and Gallipot) -- others that meets USP standards are acceptable. The USP gel powder contains 300 mg of aluminum hydroxide per 1/4 teaspoon.  A minimum of 76.5% of the weight of USP aluminum hydroxide dried gel powder is aluminum hydroxide; thus, a 500 gram tin of the product would contain 382.5 grams of aluminum hydroxide, enough to treat the typical 10 lb. cat for 1-2 years or more (see dosage protocol below).

Products  

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You should be able to buy one of the above or an equivalent USP generic at a local compounding pharmacy for $40-$65.  They may not have it in stock, but they can order it.  If you can't find it locally, ThrivingPets is the only mail order vendor currently recommended by folks who frequent this web site.

Local / Internet / Mail Order Vendors  


  • Finding Aluminum Hydroxide Dried Gel Powder Locally:  Without too much effort, you can find this product locally at substantial savings over mail order.  Because this product is used by compounding pharmacies, almost all will have it or can order it.  The aluminum hydoxide dried gel powder (USP) from PCCA (Professional Compounding Centers of America) is used by many compounding pharmacies.  Go to the PCCA Web Site at http://www.pccarx.com/.  At the top of the PCCA home page under Find a Compounder, enter your zip code and click on go.  The Web Site will show you all the compounding pharmacies in your area that carry their products.  Call or visit.  You want to buy a sealed tin of PCCA aluminum hydroxide dried gel powder (USP), one pound or 500 grams.  This is an over-the-counter (OTC) product that does not require a prescription from your vet but some pharmacies may insist you provide one.  Some pharmacies will insist on selling only to your veterinarian (allowing the vet to add additional markup).  It's much cheaper to buy from a pharmacy that will sell directly to you.  As noted above, folks who've successfully found aluminum hydroxide dried gel powder (USP) locally report paying $40-$65 for a pound or 500 gram tin.

  • ThrivingPets.com, (303) 333-1899, is a veterinary pharmacy located in Denver, Colorado, that does veterinary compounding and sells prescription and OTC medications, medical supplies and other pet supplies directly to pet owners and veterinarians. ThrivingPets.com sells Aluminum Hydroxide in 2 sizes- 1 pound or 1 ounce.  One pound of Aluminum Hydroxide Powder USP is $79.95 plus $10-$12 shipping to the lower 48. Shipping for orders over $85 is free, so it's worthwhile to purchase another $5.06 to save the shipping charge.  Note that inserting the coupon code "scooter" (small letters, no quotes) will get you a 10% discount but if your order total is $85 or less, you'll lose your free shipping.  ThrivingPets.com charges $8.95 for 1 ounce for Aluminum Hydroxide powder USP and shipping 1 ounce costs about $6 via USPS First Class Mail - good for folks who want to try it before ordering a full pound.  Feedback from ThrivingPets.com customers has been good.  ThrivingPets.com has many meds and supplies for folks treating chronically ill pets including fluids, IV sets, disposable needles, potassium gluconate powder, calcitriol, Rubenal, Azodyl, Renal Essentials, and Standard Process Renal Support among other items.

    http://www.thrivingpets.com/index.php/aluminum-hydroxide.html -
    ThrivingPets.com offers a 10% discount for users of this web site who enter the promo code  scooter  (no quotes) for orders greater than $55.

 

  • Goolricks Modern Pharmacy, 901 Caroline Street, Fredericksburg, VA  22401, 1-800-471-8674 or 540-373-3411, email - pharmacy@goolricks.com.   This site has received numerous complaints from Goolrick customers.  Goolricks claims to sell 1/2 pound containers of Aluminum Hydroxide Dried Gel Powder USP but customers have complained that a considerable part of that 1/2 pound is the weight of the container.  One recent buyer complained that although she had paid for 1/2 pound, she actually received 140 grams, about 3/10s of a pound.  Another recent buyer (October 2008) has complained that Goolricks is now demanding a prescription for aluminum hydroxide dried gel powder because of Virginia pharmacy regulations.  I personally checked with the Virginia Board of Pharmacy -- a prescription is not required by Virginia or federal authorities for this product.  Last, Goolrick's is now charging a very high price for the product -- a recent (January 2009) customer paid over $44 for the standard container that allegedly contains 1/2 pound of aluminum hydroxide dried gel powder.  Due to these complaints, we do not recommend doing business with Goolricks.

 

  • Bill's Pills Online.  Bill's has closed.

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Other Aluminum Based Binders


Basaljel (Axcan Pharma Inc.)., sold only in Canada, over the counter, a dried aluminum hydroxide gel powder and sucrose packaged in gel caps, comes in bottles of 100 gel caps.  Each 641 mg cap has 500 mg of aluminum hydroxide.  Basaljel is flavorless and mixes easily with wet food.  Basaljel can be purchased at Canadian drug stores.  PetPharm, an Ontario mail order pet pharmacy, will ship a bottle to the States from a free trade zone in the Bahamas for approximately for $32.26 including shipping.  Takes 2-3 weeks..  Cost of Basaljel itself is currently $13.76 US plus a flat shipping cost of $18.50 US.  Consider ordering more than one bottle - shipping charge will be the  same.  Toll free number is 1-888-423-9444, toll free fax number is 1-888-423-7860, email is info@petpharm.org.  Orders for OTC products can be faxed or e-mailed to PetPharm. Your order should include the following information product name, quantity, and your name, address and phone number (and email if applicable).  PetPharm's consulting vet suggested I post the following catalog information: Basaljel (Axcan Pharma) Aluminum Hydroxide, Gastrointestinal Phosphate Binder. Each yellow and red capsule contains: dried aluminum gel 500 mg (aluminum hydroxide-sucrose 641mg). nonmedical ingredients: magnesium stearate, microcrystalline cellulose and talc. Energy: 2.80 kj (0.67 kcal)/capsule. Tartrazine-free. 


Amphojel (Wyeth-Ayerst - NDC# 00008- 0010-01), an over-the-counter thick liquid suspension with 320 mg of aluminum hydroxide per teaspoonful (5 mL) (64mg/mL), available in peppermint and unflavored versions.  Comes in 12 oz bottles.  Most syringe amphojel down their cat's throats or give in gel caps. The tablet versions of Amphojel have been discontinued in the US and the liquid version is no longer distributed in the US; however, generic versions of Amphojel liquid are widely available - ask for an aluminum hydroxide suspension antacid.


Flavored Aluminum Hydroxide Suspension:

  • ThrivingPets.com. ThrivingPets supplies an unflavored Aluminum Hydroxide suspension in multiples of 30 milliliters (mLs).  30 mLs costs $18, 60 mLs is $30, 120 mLs is $48, and 300 mLs is $80.  ThrivingPets Aluminum Hydroxide suspension may be flavored upon request.  Here is a link to ThrivingPets Aluminum Hydroxide page- http://www.thrivingpets.com/index.php/aluminum-hydroxide.html.

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Calcium Based Phosphorus Binders


Calcium-based binders such as Phos-Lo and Tums are readily available and inexpensive.  But they're not as effective as the aluminum hydroxide binders, they require large doses and they are not as safe.  There is the fear that supplementing calcium in a CRF cat can lead to serious problems such as hypercalcemia, soft tissue calcification, etc. These products are mentioned for completeness -- with the exception of Epatikin (see below), I haven't heard from anyone who's actually using a calcium-based binder.


Epakitin/Ipakitine. Ipakitine has been marketed in Europe for awhile and its twin product, Epakitin, is now being heavily marketed in the US as a "nutritional supplement."  This product's active binding ingredients are calcium carbonate and chitosan.  Tests have shown the calcium carbonate binders are inferior to the aluminum-based products.  Several well-known CRF researchers advised that this product should not be used in cats with high normal or elevated calcium due to the risk of throwing such cats into hypercalcemia by adding calcium carbonate to their daily meds.  Dr. Larry Nagode of Ohio State University Veterinary College advises that the product should not be used with cats that currently get calcitriol nor cats that may get it in the future, again because of the risk of hypercalcemia.  Epatikin is being marketed directly to vets and more as a renal protectorant/preventive than as a treatment for elevated phosphorus.  I've received emails from folks in Germany and Switzerland about Ipakitine being prescribed for their early CRF cats - they report it seems to have helped their cats' appetite and energy.  None of these cats had elevated phosphorus.  Dosage recommendation is based on weight alone (1g/5kg body weight given orally in the morning and the evening mixed with food) without regard to phosphorus levels -- this further suggests that the product is intended for cats in early CRF and/or CRF cats with phosphorus in normal bounds rather than cats with elevated phosphorus where dosage is normally adjusted based on phosphorus values.  This product is expensive -- the two  retail sources currently on the web are charging $19.99 for 50 grams and $49.99 for 150 grams.  One correspondent reported purchasing this from her US vet for $100 for 150 grams!  Epakitin is an "over-the-counter" supplement.  The manufacturer, however, is marketing it mainly to veterinarians and some vendors may insist on a "veterinary prescription."

David's Advice:  Epakitin may be worth a try for cats in early CRF that do not have elevated phosphorus.  Once a cat's phosphorus is elevated (6 or more), however, aluminum-based binders are more effective in bringing the values down quickly. One CRF researcher advised that Epakitin can be used in combination with the aluminum-based binders.  Please be aware that Epakitin is the only phosphorus binder currently being marketed directly to US vets for resale to their clients.  Some clinics may push Epakitin because they profit from it and/or it's the only binder they know.  And some may prescribe this medication inappropriately for cats in crisis with elevated phosphorus.  Further, this product is very expensive and since its major ingredients are all inexpensive -- lactose, calcium carbonate and chitosan -- most of the product's cost is marketing and profit!

Mail Order Sources:

  • Healthypets.com sells 50 gm for $13.99 and 180 gm for $37.99 and 300 gm for $35.69.  Shipping is a flat $4.95 for orders under $85, free for orders of $85 or over.
  • EntirelyPets.com sells 50 gm for $13.99 and 180 gm for $37.99 and 300 gm for $41.99.  Shipping is a flat $4.95 for orders under $85, free for orders of $85 or over.
  • VetDepot sells 60 gm for $17.87, 180 gm for $39.87 and 300 gm for $56.97.  Standard shipping for orders less than $69 is $4.99  to the lower 48.  Shipping for orders of $69 or more is free.
  • ThrivingPets.com sells 60 gm for $24.95 and 150 gm for $54.95 and 300 gm for $79.95.  Shipping varies by location and service but typically runs $5-$10.  Orders over $60 ship free.  Orders over $55 get a discount with coupon code scooter  (no quotes).

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Renagel, Fosrenol, Renvela



Renagel (Genzyme), prescription only, is sevelamer hydrochloride, a polymeric phosphate binder intended for oral administration. It's calcium and aluminum free.  Vets sometimes prescribe it (in 403 mg gel caps) when cats refuse other products.  It is expensive (70-80 cents per cap) and has side effects.  Use only under the direction of your vet.  Available at most pharmacies.

Fosrenol (lanthanum carbonate), prescription only, is a phosphate binder used for reducing serum phosphate levels in patients with end stage kidney (renal) disease.  Fosrenol tablets should be completely chewed before swallowing so the medication is rarely prescribed for pets.  Available at most pharmacies.

Renvela (sevelamer), prescription only, is a phosphate binder. Available at most pharmacies.

The three medications above are prescribed for pets only when more common binders such as aluminum hydroxide cannot be tolerated or fail to work.  All are prescription-only and very expensive.  Aluminum hydroxide binders are still the drug of choice (or gold standard) for controlling phosphates in pets.  Aluminum toxicity, a concern in humans, is not an issue for cats and dogs.

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Dr. Nagode's Phosphorus Binder Protocol / Dosage



Dosage: Many in the Yahoo Feline CRF Support Group and the Yahoo Feline Phosphorus Management Group use the dosage protocol recommended by Larry Nagode (DVM Ph.D.) of The Ohio State University Veterinary College.  Dr. Nagode recommends treating animals with phosphorus values over 6 with aluminum hydroxide binders.  Dosage is based on the animal's phosphorus values and body weight.  Please note that a phosphorus value of 6 is within the "normal range" of many veterinary laboratories for cats -- Dr. Nagode advises that those "normal ranges" average the ranges for both kittens and cats and that adult cats should be treated for values of 6 or over.
 

Phosphorus Values (mg/dl)

Daily Dosage per kg / lb of body weight

6 - 7.99

100 mg/kg or 50 mg/lb

8 - 9.99

200 mg/kg or 100 mg/lb

10 or Over

Higher - Consult Your Vet

Thus, a 10 lb cat  with a phosphorus value of 7 would get a dose of about 500 mg of aluminum hydroxide binder a day, with that dose divided between the cat's meals.  A 10 lb. cat with a value of 9 would get 1000 mg of aluminum hydroxide binder, again with the dose divided between the cat's meals.

Dr. Nagode indicates that it's always better to err on the side of giving a cat more rather than less binder, and that he favors ramping up the dosage quickly if the cat is not responding to lower doses.  Dr. Nagode's recommended dosages run about double what many vets believe is appropriate!  If the dosages above do not promptly bring down the cat's values, Dr. Nagode suggests doubling them!

Delivery:  The binder must be in the cat's gut when food is being digested so that it can bind with phosphorus before it's absorbed and carry it out of the cat's system.  That's why dry food left out  for "as needed feeding" requires binder. Many mix portions of dry food with dried aluminum hydroxide gel binder in a plastic "baggie" overnight - the binder is absorbed by the dry food and then can be left out for the cat.  Again, always better to err on the high side in binder dosage.

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Folks using aluminum hydroxide dried gel powder often recommend a set of mini-measuring spoons to parcel out the exact dose  The set includes five measures from 1/4 teaspoon to 1/64 teaspoon--a tad, a dash, a pinch, a smidgen, and a drop -- and costs anywhere from $3 to $6.  You can find it at your local Bed, Bath and Beyond or at a cooking shop or online at Amazon.com

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Teaspoons / Tablespoons to Milliliters (mL)


Teaspoons /
Tablespoons

 


Milliliters (mL)

1/4 teaspoon


1.25 mL

1/2 teaspoon


2.50 mL

3/4 teaspoon


3.75 mL

1 teaspoon


5.00 mL

1 1/4 teaspoons


6.25 mL

1 1/2 teaspoons


7.50 mL

1 3/4 teaspoons


8.75 mL

2 teaspoons


10.00 mL

1 tablespoon


15.00 mL

2 tablespoons


30.00 ML

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This page is the product of me, David Jacobson. The information presented here is not guaranteed.  Contact the vendors listed directly for their current prices and policies.  Feel free to link this page to other pages and web sites dealing with the medical treatment of cats and dogs.  And please contact me with any updated information or additional vendors, or your comments, criticisms and suggestions.  I appreciate your help.

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