Phosphorus Binders - What You Need to Know

Introduction

With luck, your cat is going to live a long time with CRF. To start with, if your cat only has mild CRF, you may not need many supplies; but as the disease progresses, you may need various items, and the cost can soon add up. This section provides information on obtaining supplies at reasonable prices in the USA, UK and Canada. By saving money in this way, you have more money available for tests and bloodwork with your vet.

For holistic supplies, see Holistic Treatments. For Epogen, Procrit or Eprex, see the Anaemia page. For supplies in German-speaking countries, see Tanyas CNI Webseite.

Phosphorus Binders - What You Need to Know

It is important to control phosphorus levels in CRF cats, because high phosphorus levels may make the CRF progress faster, and may also make the cat feel ill. Phosphorus binders are used when dietary restriction of phosphorus is no longer sufficient to keep a cat's phosphorus levels low. The main types of phosphorus binders are based on either aluminium hydroxide or calcium. Please see the Treatments section for the pros and cons of each type. Binders containing aluminium hydroxide are generally considered to be the most effective type.

You may have read that there is a risk of aluminium toxicity from the aluminium in aluminium hydroxide medications but this refers to human patients on dialysis (because aluminium is used in the dialysis process); even then it takes years before it becomes an problem, so it is not an issue for cats.

If you buy aluminium hydroxide gel or powder, you may see a warning about arsenic which bizarrely supposedly only applies to people living in California. This is to comply with that state's legal requirements. The fact of the matter is that aluminium hydroxide is a naturally occurring product which is mined, and therefore it contains a naturally occurring tiny amount of arsenic of no more than 8 parts per million. This is no more than you might find in soil or in vegetables grown in soil. However, if you want to be on the safe side, you might wish to avoid inhaling the powder.

The aim is to get phosphorus to a level of around 1.3 mmol/L (US: 4 mg/dl). Here are the usual dosages:

*Not everybody chooses to start binders if phosphorus levels are in this range - most people only start binders once phosphorus levels are over 1.3 (US: 6.0). However, if your cat has previously had high phosphorus levels which you have reduced with binders, you will probably need to continue to give binders, either at this dosage or even higher, otherwise your cat's values will probably rise over 1.3 (US: 6.0) again.

Phosphorus binders must be given with food so they can bind with the phosphorus in it. If you are using tablets, you can simply crush them up and add them to the food; while capsules can be opened and the tasteless contents mixed with the food. If you are using dry food, you may wish to try putting the food in a freezer bag together with the crushed binder and leave them to mingle overnight. 

Aluminium hydroxide is a safe product, so it does not have to be measured too precisely, but as a rough guide, if you are using powdered aluminium hydroxide, such as the Spectrum brand sold by Goolricks, a quarter of a teaspoon of powder contains approximately 300mg of aluminium hydroxide. If you are using a liquid type of binder, as a guide, a teaspoon of Alternagel contains approximately 600mg of aluminium hydroxide.

Sometimes phosphorus binders may cause constipation, so watch for this when you first start them. Phosphorus binders should be given two hours apart from Baytril (an antibiotic), Pepcid (famotidine) or ACE inhibitors.

It does not matter if your non-CRF cats eat food mixed with phosphorus binders, though obviously you should try to give them some food free of binders too, particularly kittens.

Aluminium-Based Binders

There is a wide variety of aluminium hydroxide binders on the market so it can be very confusing knowing which to use. The list below was provided by an American pharmacist. All the products listed here are odourless and tasteless, apart from Basaljel liquid and AlternaGel, which are apparently peppermint flavoured. Amphojel comes in both unflavoured and peppermint flavoured forms, so check before you buy that you will be getting the unflavoured form.

USA

In the USA it is easy to find supplies  which are very reasonably priced, either online or at local pharmacies. A prescription is usually required for fluids and/or needles - if your vet refuses to write a prescription, you may be able to insist that s/he does so, depending upon which state you live in - David Jacobson's Pages  have more information on this.

David Jacobson's Pages - detailed focus on obtaining sub-Q supplies. Compares suppliers and has up to date prices and comparisons.

Linda's Feline CRF Hints - has detailed information on sources for drugs commonly used in CRF cats.

Pillbot - finds the least expensive US source for prescriptions drugs.

Walmart and Target both sell a number of generic medications, such as Lactulose or benazepril, for US$4 for a month's supply.

Fluids - USA

If you buy your fluids online, a case of 12 bags of 1000ml sub-Q fluid costs around US$35-44, including shipping. A prescription is required.

• Some branches of Costco will sell a case of fluids to you in person for as little as US$16, and of course you pay no shipping costs. Target, CVS and Walgreens can also often obtain fluids for you cheaply, usually for under US$30 a case. In some cases you can even sign your cat up as a member of the discount scheme and get a discount. One Feline CRF Information list member was quoted US$58 for a case of 12 x 1000ml bags of fluid at Walgreens, but after signing her cat up on the discount scheme at a cost US$20 a year, she was able to get the fluids for only US$13! If you go this route, you often need the NDC code so they can order exactly what you need.

• Valley Vet sells a case of 12 x 1000ml bags for US$39.48, plus US$6 shipping for orders under US$60, free shipping over US$60. I have used Valley Vet myself for other items and have always received fast and efficient service.

• An alternative supplier for the Eastern US is Direct Medical, where you can buy a case of 12 x 1000ml bags of lactated ringers for US$28.20 plus approximately US$22 for shipping.

• UPCO sells 1 x 1000ml bag for US$4.95, but 14 x 1000ml bags cost $55.50 (equivalent to US$47.40 for 12). Shipping costs US$5 but is free with orders over US$75. Search for lactated ringers. The price on the website reflects the price of buying one bag of fluids only: if you enter 14, you should find the price is reduced automatically.

• Thriving Pets sells 14 bags of fluid for US$28. Delivery costs US$25 anywhere in the lower 48 states. You can also buy 12 bags for US$23 plus delivery of US$20.

• If you are looking for 500ml bags of lactated ringers, Brico Medical Supplies sell 24 of these for $72.80 plus shipping of between US$14.50 (East Coast) - US$26 (West Coast). Brico also sell 1000ml bags, at US$47.50 for 12. Brico are renowned for very good, personal service.

• David Jacobson's Pages have more detailed information on ordering from the above suppliers.

Needles and Syringes - USA

A prescription is required for needles in CT, IL, MA, NJ, NY and RI.

• Thriving Pets sells Terumo needles for US$6.50 per 100, plus shipping of US5.

• Brico Medical Supplies charges US$6.25 per 100 needles, plus shipping of US$6.75.

• Med Care Products sell 100 Terumo needles for US$6.95, apparently without a prescription. Shipping costs US$6.50, and there is an additional minimum order fee of US5 if your order is for less than US$75.

• Farris Laboratories apparently also sell needles without a prescription; 100 cost US$8.25.

• Direct Medical charges US$8.50 plus shipping.

• Medi-Vet also sells needles without a prescription for around US$8-10, although if one is required in your state, they will need to see it. 

Winged Infusion Sets (Butterfly Needles)

You may wish to use winged infusion sets as we used for Thomas (see How to Give Sub-Cutaneous Fluids: Syringe Method).

• Farris Laboratories sells the Terumo brand at US$21.95 for 50;

• Thriving Pets sells these for US$22.98 for 50 Terumos, in sizes 19 or 21.

• Brico Medical Supplies sell these at US$23.50 for 50 Terumos, in sizes from 18 to 21 gauge;

• Lambriar Animal Health Care charge US$25 for a box of size 23 gauge, or 50 cents each for the 21 gauge size;

• Direct Medical sells them at US$25.95 for 50 (brand unspecified);

• M & M Medical Sales sells a variety of sizes from US$34.50 for a box of 50;

• You need to factor in shipping costs to your destination to work out which of these suppliers would be the cheapest one for you.

Syringes

• Lambriar Animal Health Care sells syringes (without needles) in a number of different sizesbut they don't sell in small quantities (their minimum order appears to be 50 for the 20ml size, costing US$28.71): since you can re-use syringes when using the syringe method, it might be cheaper just to get as many as you need from your vet.

• KCK Medical also sells syringes, a box of 40 regular luer tip 20ml syringes costs $25.97. 

• Please see the Persuading Your Cat to Eat page for information on obtaining smaller syringes for assist feeding purposes.

Phosphorus Binders - USA

Please see aluminium-based binders for more information on the types of binders available. Most people on the Feline CRF Information list these days use the loose gel available from the pharmacies below or from their local pharmacy. You may be told that a prescription is required, but this is not correct, but it may take a local pharmacy a few days to obtain it for you.

• Thriving Pets (Vet Pet Solutions) in the USA sells 500g (1.1 lbs) of aluminium hydroxide dry gel  for US$40, with shipping & handling anywhere in the continental US costing US$10, giving a total price of $50. It also sells 250g of aluminium hydroxide.

• The Medicine Shoppe Animal Pharmacy sells a pound of flavoured (to a cat's taste) aluminium hydroxide for US$27-39. The Medicine Shoppe Animal Pharmacy is a franchise, and if you have a branch near you, they should be able to obtain aluminium hydroxide (usually Spectrum brand) for you within a couple of days; some branches may even have it in stock.

• Goolricks Pharmacy will ship aluminium hydroxide dry gel (Spectrum brand) throughout the world, although you cannot order online as yet (you have to telephone). It costs around US$45 for half a pound plus shipping and handling. Goolricks will ship abroad. Unfortunately Goolricks have recently started asking for a prescription, even though aluminium hydroxide is not a prescription product.

• David Jacobson's Site has information on obtaining phosphorus binders in the USA.

Basaljel

There used to be a product called Basaljel available in the USA. However, unlike the Canadian Basaljel mentioned above, the US version of Basaljel was not aluminium hydroxide - it was aluminium carbonate, as Island Pharmacy explains. If you are keen to try this, you could try to have it compounded by a compounding pharmacy into a flavour acceptable to cats (see compounding pharmacies). Personally, I'd simply use the other products available.

Prescription Diets - USA

• Pet Food Direct sells Hi Tor Neo, a low protein, low phosphorus food which does not require a prescription. Shipping can be expensive, but there are regular 20% off sales which can help offset the cost.

• Waggintails also sells Hi Tor Neo without prescription.

• Southern Agriculture sells prescription diets from Purina, Royal Canin IVD, Waltham Royal Canin, Eukanuba and Hill's.

• RX Petfood also sells prescription diets from Purina, Royal Canin IVD, Waltham Royal Canin, Eukanuba and Hill's. They need a prescription or contact details for your vet. I do not know of anybody who has used them as yet.

• You may also wish simply to buy in bulk from your vet. Our cat, Harpsie, needed a prescription food which cost US$2 per 5.5 oz can. However, when we bought a case, the price fell to US$1.40 a can, a very worthwhile saving.

UK Supplies

In the UK it can be hard to find things cheaply but here are a few possible sources:

Fluids - UK

• Vetscriptions sells Hartmann's Aqupharm No.11 for £5.99 per litre. It also sells fluids in 500ml bags if required for £4.99 each (search for Hart500). A prescription is necessary.

• Vet-medic can supply fluids (prescription required) and needles. One litre of Hartmann's Aqupharm No.11 costs £4.95, while a case of ten x 1 litre bags costs £42.89 including shipping. It also sells fluids in 500ml bags if required (£4.11 each). Vet-medic also sells a limited number of what are considered prescription-only treatments as opposed to prescription-only drugs.

Needles- UK

• Direct Medical sells 50 Terumo 21g winged infusion sets for £35.99, with carriage costing a flat £8. Click on Needles, then on Butterfly, ot quote product code MN-SV21. You have to register in order to use this website.

• Western Laboratory Service sells Terumo needles at around £5.26 for 100, and winged infusion sets for around £27.03, including delivery.

• Vet-medic can supply needles. They are not able to obtain Terumo winged infusion sets (as we used for Thomas) but sell the Anicanth brand for about 70p each. They do not appear to charge delivery on orders over £20.

Phosphorus Binders - UK

• Alucaps are an odourless and flavourless phosphorus binder in the UK. In 2006 they cost £7.10 from Boots for 120 capsules of 475mg aluminium hydroxide. I had to ask the pharmacist, who had never heard of it, but who - unknown to her - did actually have some in stock; so you may need to be persistent or ask for it to be ordered for you. If it needs to be ordered, it only takes a couple of days to arrive. 

• If you cannot find Alucaps, we used a product for Thomas called Aludrox Liquid (aluminium hydroxide), made by Pfizer, which cost £4.49 at Boots. However, it was mint-flavoured, plus it contained magnesium, so it was not the best choice (see Treatments).  

• Thriving Pets (Vet Pet Solutions) in the USA sells 500g (1.1 lbs) of aluminium hydroxide dry gel  for US$40, and will ship to the UK and elsewhere. Contact them to obtain a quote for shipping & handling costs.

• Goolricks Pharmacy in the USA will ship aluminium hydroxide dry gel (Spectrum brand) throughout the world, although you cannot order online as yet (you have to telephone). It costs US$45 for half a pound plus shipping and handling. Unfortunately Goolricks have recently started asking for a prescription, even though aluminium hydroxide is not a prescription product.

Prescription Foods - UK

• Animal Medicines sell Eukanuba, Hill's and Royal Canin prescription diets. As an example, a 2kg bag of Royal Canin Renal food costs £13.89, while 24 156g tins of Hill's k/d cost £22.33.

• Medic Animal sells a number of prescription foods. As an example, a 2kg bag of Royal Canin Renal food costs £14.58, while 24 156g tins of Hill's k/d cost £22.66. They offer free delivery for orders over £29. and deliver quickly (often the next day).

• Best Pet Pharmacy sells a variety of prescription diets, some without a prescription. As an example, a 2kg bag of Royal Canin Renal food costs £14.38, while 24 156g tins of Hill's k/d cost £22.68. Shipping is free for orders over £60.

• Vet-medic are able to provide prescription diets cheaply if required. 

• You may also wish simply to buy in bulk from your vet. Our cat needed a prescription food which cost US$2 per 5.5 oz can. However, when we bought a case, the price fell to US$1.40 a can, a very worthwhile saving.

Canadian Supplies

Fluids - Canada

• Medical Mart can provide many supplies within Canada e.g. a 1000ml bag of lactated ringers costs CAN$4.95, or CAN$49.95 for 12 with no prescription required. Shipping is extra. Go to page 3 of their 2007 dental catalogue.

• Prescription Point (formerly Maple Leaf Meds) advertise as if they only supply to US customers but they will in fact supply to Canadian customers as well, albeit only if you live outside the state where they are located (British Columbia). The prices quoted on the site are in US dollars.

• Pacific Health Care sells 1000ml bags of LRS for CAN$3.35. You need to log in before you can access the website and view their catalogue, but if you want to check it out, either call or e-mail them (contact details are on their site) and they will send you a temporary login and password. They have advised me that shipping costs to those outside BC may mean it would be cheaper for such people to try to find a more local supplier. 

• Canada Drugs also advertise as if they only supply to US customers but they will supply to Canadian customers as well, albeit only if you live outside the state where they are located (Manitoba). Again, the prices quoted on the site are in US dollars.

• Stat Health Care is a wholesale distributor in Calgary which sells one litre bags of lactated ringers for CAN$3.50 per bag, with a flat fee shipping charge of CAN$6-10. This company only sells within Alberta. The phone number is 403-297-0700.

• One person found the cheapest place to obtain LRS fluids in Canada was from her local hospital's pharmacy - items not in stock can usually be ordered overnight and will be available for collection the next day.

Needles - Canada

• Pacific Health Care sells needles at CAN$6.65 for 100. It looks like you would need to create an account and be accepted as a customer first.

• Medical Mart sells needles for CAN$6.99 per 100.

Phosphorus Binders - Canada

• Xenex Laboratories in Canada sells 500g of aluminium hydroxide for CAN$31.20.

• Petpharm sells Amphojel in tablet or liquid form for CAN$8.39. You can grind the tablets up if required and mix them with your cat's food.

• Petpharm also sells an aluminium hydroxide based binder called Basaljel made by Axcan Pharma Inc. It comes in gelcaps, each containing 500 mg of aluminium hydroxide, and they cost CAN$14.31 for 100. Basaljel is also available over the counter in many Canadian pharmacies.

• Canada Drugs sell a liquid aluminium hydroxide product called Alugel for CAN$5.39.

• Thriving Pets (Vet Pet Solutions) in the USA sells 500g (1.1 lbs) of aluminium hydroxide dry gel  for US$40, and will ship to Canada and elsewhere. Contact them to obtain a quote for shipping & handling costs.

• Goolricks Pharmacy will ship aluminium hydroxide dry gel (Spectrum brand) throughout the world, although you cannot order online as yet (you have to telephone). It costs US$45 for half a pound plus shipping and handling. Unfortunately Goolricks have recently started asking for a prescription, even though aluminium hydroxide is not a prescription product.

Prescription Foods - Canada

• I'm afraid I haven't heard of any cheap food suppliers based in Canada as yet. If you know of any, please contact me. In the meantime, you may wish simply to buy in bulk from your vet. Our cat needed a prescription food which cost US$2 per 5.5 oz can. However, when we bought a case, the price fell to US$1.40 a can, a very worthwhile saving.

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