Higher serum phosphate and fibroblast growth factor-23 (FGF23) levels are potential modifiable risk factors to prevent cardiovascular disease in CKD. Studies evaluating intestinal phosphate binders found modest efficacy for lowering phosphate and FGF23 levels during short-term follow-up in CKD. In their randomized, placebo-controlled trial in 205 participants with stage 3b/4 CKD, the authors evaluated the effects of nicotinamide (an inhibitor of active intestinal phosphate transport), the phosphate binder lanthanum carbonate, or both, versus placebo over 12 months. They found that neither drug, alone or together, reduced serum phosphate or FGF23. Participants taking lanthanum carbonate had reductions in urinary phosphate, however gastrointestinal symptoms limited adherence. Secondary on-treatment analyses suggest that blocking intestinal phosphate absorption may lower FGF23, suggesting potential opportunities for future studies using novel therapies with better tolerability.