Risk factors for and effects of persistent and severe hypophosphatemia following ferric carboxymaltose
Abstract Context Hypophosphatemia, osteomalacia and fractures are complications of certain intravenous iron formulations. Objective To investigate risk factors for incident, severe and persistent hypophosphatemia, and associated alterations in bone and mineral biomarkers following intravenous iron treatment. Design Secondary analysis of the PHOPHARE-IDA randomized clinical trials. Setting Thirty outpatient clinics in the United States. Patients 245 patients aged 18 years or older with iron deficiency anemia. Interventions Intravenous ferric carboxymaltose (FCM) versus ferric derisomaltose (FDI). Main Outcome Measures Serum phosphate, intact fibroblast growth factor-23 (iFGF23), 1,25-dihydroxyvitamin D (1,25(OH)2D), ionized calcium, parathyroid hormone (PTH), and alkaline phosphatase. Results FCM was the only consistent risk factor for incident hypophosphatemia (<2.0 mg/dl; odds ratio versus FDI: 38.37; 95% confidence interval [CI]: 16.62, 88.56; p<0.001). Only FCM-treated patients developed severe hypophosphatemia (<1.0 mg/dl; 11.3%; 13/115) or persistent hypophosphatemia (<2.0 mg/dl at study end; 40.0%; 46/115). More severe hypophosphatemia associated with significantly greater increases in iFGF23, PTH, and alkaline phosphatase, and more severe decreases in 1,25(OH)2D and ionized calcium (all p<0.05). Patients with persistent versus resolved hypophosphatemia demonstrated significantly greater changes in iFGF23, PTH, 1,25(OH)2D and N-terminal procollagen-1 peptide levels (all p<0.01), but alkaline phosphatase increased similarly in both groups. Conclusions Treatment with FCM was the only consistent risk factor for hypophosphatemia. Patients who developed severe or persistent hypophosphatemia after FCM treatment manifested more severe derangements in bone and mineral metabolism. Changes in bone biomarkers continued beyond resolution of hypophosphatemia, suggesting ongoing effects on bone that may help explain the association of FCM with osteomalacia and fractures.