How do you approach the management of persistent hyperphosphatemia in ESKD patients who are non-adherent to phosphate binders?

This is not easy. The first thing I usually do is try and find out why they are non-adherent. Is it due to side effects, cost, etc? Are there social reasons? For example, are they "embarrassed" to take binders if they are out eating with friends?

Often, I find that I need to switch binders to see if it helps and use stronger binders that have less pill burden. I often switch patients to sucroferric oxyhydroxide since there is less pill burden than with sevelamer. Also, it can be dissolved in water so if there are social issues I have them put it in their water bottle so no one knows they are "taking pills".

Finally, I usually celebrate small wins in phosphate with patients. For example, if their phos was over 10 and now it is 8, I applaud ...