Stop Kerendia and Give Lokelma
With a potassium of 5.6 mEq/L, you should immediately hold Kerendia (finerenone), consider adjustments to diet or concomitant medications to mitigate hyperkalemia, and recheck potassium—you can restart finerenone at 10 mg daily when potassium is ≤5.0 mEq/L. 1
Management Algorithm Based on KDIGO 2024 Guidelines
The KDIGO 2024 guidelines provide explicit, evidence-based thresholds for finerenone management based on potassium levels 1:
For K+ >5.5 mmol/L (5.5 mEq/L):
- Hold finerenone immediately
- Consider adjustments to diet or concomitant medications to mitigate hyperkalemia
- Recheck potassium
- Consider reinitiation if/when K+ ≤5.0 mmol/L
Your patient's potassium of 5.6 mEq/L falls into this category, making discontinuation of Kerendia the guideline-directed approach.
Role of Lokelma (Sodium Zirconium Cyclosilicate)
Yes, you should give Lokelma to facilitate potassium reduction and enable eventual reinitiation of finerenone. The FDA-approved dosing for initial treatment of hyperkalemia is 10 g three times daily for up to 48 hours 2. This approach aligns with contemporary hyperkalemia management that prioritizes maintaining disease-modifying therapies like finerenone.
Why Use a Potassium Binder?
The 2022 KDIGO/ADA consensus and 2024 KDIGO guidelines emphasize that finerenone provides proven kidney and cardiovascular benefits in patients with type 2 diabetes and CKD 3. Simply discontinuing finerenone permanently would deprive your patient of these benefits. Potassium binders like SZC enable:
- Rapid potassium reduction (median time to normalization 2.2 hours) 4
- Sustained normokalemia allowing continuation of RAAS inhibitors and MRAs 5, 6
- Higher rates of finerenone continuation compared to no intervention 7, 8
Recent evidence shows SZC is associated with improved maintenance and optimization of RAAS inhibitor therapy (RR 1.26 for maintenance; RR 1.47 for up-titration) 8.
Practical Management Steps
- Immediately hold Kerendia 10 mg
- Start Lokelma 10 g three times daily for up to 48 hours 2
- Review and adjust contributing factors:
- Dietary potassium intake
- Other medications (NSAIDs, potassium-sparing diuretics, trimethoprim)
- Consider increasing loop diuretic dose if appropriate
- Assess for metabolic acidosis
- Recheck potassium within 24-48 hours
- When potassium ≤5.0 mEq/L:
Important Caveats
Monitor for edema with Lokelma: Each 5 g dose contains approximately 400 mg of sodium. Watch for fluid retention, particularly if your patient has heart failure or should restrict sodium intake 2. Adjust diuretics as needed.
Avoid severe constipation: Do not use Lokelma if the patient has severe constipation, bowel obstruction, or impaction 2.
Medication timing: Other oral medications should be administered at least 2 hours before or after Lokelma to avoid binding interactions 2.
Long-term strategy: The goal is not just to lower potassium acutely, but to maintain normokalemia while continuing finerenone therapy. Studies show that with appropriate potassium monitoring and management strategies (as employed in the FIDELIO-DKD trial), the impact of hyperkalemia can be minimized 9. In FIDELIO-DKD, 21.4% of finerenone-treated patients experienced mild hyperkalemia (>5.5 mmol/L), but routine monitoring and dose adjustments allowed most to continue therapy.
Consider SGLT2 inhibitors: If not already prescribed, SGLT2 inhibitors reduce hyperkalemia risk and should be part of comprehensive CKD management 1, 9.
The evidence strongly supports using potassium binders to enable continuation of disease-modifying therapies like finerenone rather than accepting permanent discontinuation due to a single episode of hyperkalemia 10, 11.