Do you prefer to add an additional phosphate binder or increase the dose of an existing binder in patients with ESKD and hyperphosphatemia?

The short answer is to add a binder.

The best case for this is with Ca-based binders, for which many experts recommend a maximum daily dose of 1 gm of elemental Ca.

(That’s only 6 CaAc tabs -169 mg of Ca per 667 mg).

Another limit that is supported by some data is for sevelamer. The binding per 800 ...

I would go with Tenapanor, it is very effective and can generally significantly decrease the binder dosing. The biggest problem with Tenapanor is an increase in stools, not necessarily overt diarrhea. Counsel the patient, have them stop stool softeners and laxatives, and may want to start with 1 pil...

In general, I prefer to increase the dose of an existing one, as sometimes patients don't do well with frequent medication changes. However, it all depends on how many binders they are taking, are they tolerating the current binder, how much does the serum phosphorus needs to come down by, etc.?

I would generally try to increase the dose of an existing binder if being tolerated and no other reason to change. One less medication to keep track of, one less copay, etc.