0:19
Hello, my name is Rory Pace.
0:21
I'm a board certified Specialist in renal nutrition with over 25 years of experience caring for people with chronic kidney disease and on dialysis.
0:30
As a renal dietitian, one of my primary focuses is helping dialysis patients manage their phosphorus levels.
0:37
Our best evidence indicates that achieving a phosphorus level in the normal range, usually between 2.5 and 4.5, is associated with the best outcomes.
0:46
Although reaching that range can be a serious challenge, I'd say the majority of dietitians continue to aim for a target of 3.5 to 5.5 from the older Kedoki guidelines, which most patients struggle to achieve.
1:00
Unfortunately, in my experience, probably fewer than half consistently achieve phosphorus levels within the target range.
1:07
The exact percentages vary from clinic to clinic and region to region, and frankly, even month to month.
1:14
It's easy to fall into the habit of watching and waiting to think, OK, phosphorus is high this month, but it was OK last month, it'll probably be OK next month.
1:25
We tend to look for reasons to justify out of target lab results.
1:29
Oh, it was a holiday or a birthday where the patient had some other variants this month and hope for better outcomes the next time.
1:38
But the reality is that it's challenging for patients to manage their phosphate levels and they need our expert support.
1:45
It's really important to focus on the overall picture when looking at lab values versus looking at each month in isolation.
1:52
A phosphorus lab that is out of range every other month is not a good trend and it should drive us to act in support of our patients.
2:01
It's easy to get frustrated and even complacent, but phosphorus control impacts patient's health and well-being, so it's important to not just throw our hands up and tell ourselves that getting to goal consistently can't be done, especially now that we have more tools to manage phosphate.
2:22
When it comes to managing phosphorus, as dietitians, we naturally talk to patients about their food choices.
2:28
First, because phosphorus is abundant in our food supply and is associated with protein foods, dietary changes are not usually sufficient for managing phosphate.
2:38
I always go to a discussion about medication next.
2:42
For most of our patients, medication is needed to manage phosphorus.
2:46
When phosphorus is high in patients on a binder, the standard has been to counsel patients on their diet and binder adherence and then typically to increase the phosphate binder dose.
2:56
Unfortunately, these actions do not often result in good phosphorus control and may frustrate patients with increasing pill burdens, potentially worsening medication adherence.
3:07
But these have been the phosphate management approaches we've turned to because that's what we've had as options.
3:13
I'm excited that we now have Exposa.
3:16
Exposa is the only medication that is specifically indicated for adult patients on dialysis to reduce serum phosphorus as add on therapy.
3:24
When a phosphate binder does not work well or when patients are intolerant to any dose of a phosphate binder exposes a different kind of medicine to lower phosphorus.
3:34
Exposa is not a phosphate binder.
3:36
Exposa is a first in class phosphate absorption inhibitor, or Pai.
3:41
Exposa works by blocking phosphorus absorption via the paracellular pathway.
3:47
Exposa is dosed as 130 milligram pill twice a day.
3:51
The most common adverse reaction is diarrhea, which occurred in 43 to 53% of patients.
3:57
The majority of diarrhea was reported to be mild to moderate.
4:01
Severe diarrhea was reported in 5% of patients.
4:04
If diarrhea occurred, it tended to be reported soon after initiation and resolve over time or with dose reduction what could occur at any time during treatment.
4:14
We have a tool that works differently, and having more tools in the toolbox allows us to better individualize care for patients who are not at goal.
4:22
With the availability of Exposa when a dialysis patient on a binder has a phosphorus level above target, I think it makes sense to consider adding Exposa.
4:36
When considering which patients might benefit from adding Exposa, it makes sense to look at lab values first.
4:42
For patients on a binder who would not meeting target phosphorus levels, adding Exposa with its different mechanism of action may help.
4:50
Exposes specifically for dialysis patients who are on a binder and not meeting phosphate goals, patients on a binder that are always significantly above goal, patients on a binder that fluctuate in and out of the target range, and patients on a binder who hover just above goal would all be appropriate candidates for Exposa.
5:10
The concept of close enough to goal doesn't have to be good enough for our patients.
5:15
The option to add Exposa gives us a different strategy to help our patients.
5:21
I think that as dietitians, we are the phosphorus management champions.
5:25
We're the clinicians on the team who typically have the most contact with patients and are the most knowledgeable about the bigger picture of phosphorus management and the numerous factors at play, including food choices, eating patterns, and medication utilization.
5:58
With extensive knowledge and frequent interactions with our patients, I think the dietitian should feel comfortable and confident discussing potential medication changes with nephrologists.
6:08
As we develop trusted relationships, nephrologists rely on us to collaborate in medication management to ensure timely and appropriate care for patients.
6:18
With the availability of Exposa, I think it's time to rethink our approach to phosphorus management and take a different action than we have in the past.
6:26
When we see a patient on a binder with elevated phosphorus, we can't just keep doing the same things we have been doing and expect different results.
6:34
We owe it to our patients to remind nephrologist about Exposa and suggest adding it for dialysis patients on a binder with phosphorus above target.
6:49
Patients are more likely to be successful starting a new medication when they know what to expect.
6:54
When starting a patient on Exposa, it's important to tell them about how Exposa works and what they may experience in terms of side effects.
7:01
The most common side effect is diarrhea, and that's something I think is important to proactively discuss with patients.
7:08
I think it is important to provide patients with context of why they may experience softer and or more frequent stools, remind them what is normal and what is not, and make sure they know to stop their stool softeners or laxatives.
7:22
I think it's good practice to provide the name of the specific stool softener or laxative they are on so they know the right medication to stop.
7:31
It's also important to explain that Exposa is different than binders and is not taken like a phosphate binder.
7:38
Patients are used to taking binders with every meal and this is not something they should do with Exposa, which is dosed as 130 milligram tablet twice a day, one pill before the morning meal and one pill before the evening meal.
7:52
Ultimately, my goal is to empower each patient with the tools and information they need to take control of their phosphorus management.
7:59
Managing phosphorus is complex, but with different tools and an individualized plan, we can give patients the best chance to reduce their phosphorus and achieve their goals.
8:11
Exposa to Napinor Indication and Important safety information indication exposa tenaponor 30 milligram BID is indicated to reduce serum phosphorus in adults with chronic kidney disease CKD on dialysis as add on therapy in patients who have an inadequate response to phosphate binders or who are intolerant of any dose of phosphate binder therapy.
8:41
Important safety information Contraindications Exposa is contraindicated in pediatric patients under six years of age.
8:52
Patients with known or suspected mechanical gastrointestinal obstruction.
8:58
Warnings and precautions Diarrhea Patients may experience severe diarrhea.
9:05
Treatment with exposure should be discontinued in patients who develop severe diarrhea.
9:11
Most common adverse reactions diarrhea, which occurred in 43 to 53% of patients, was the only adverse reaction reported in at least 5% of exposa treated patients with CKD on dialysis.
9:27
Across trials, the majority of diarrhea events in exposa treated patients were reported to be mild to moderate in severity and resolved over time or with dose reduction.
9:39
Diarrhea was typically reported soon after initiation but could occur at any time during treatment with exposa.
9:47
Severe diarrhea was reported in 5% of exposa treated patients in these trials.
9:53
For additional safety information, please see full Prescribing Information available at exposadashhcp.com.
Salvatore Chillemi
MOA
Andrew Lazar