Renal Dosing of Lokelma (Sodium Zirconium Cyclosilicate)
For patients on chronic hemodialysis, Lokelma should be administered only on non-dialysis days with a recommended starting dose of 5 g once daily, which can be increased to 10 g once daily for patients with serum potassium >6.5 mEq/L. 1
Dosing Guidelines for Patients with Renal Impairment
Patients on Chronic Hemodialysis
- Starting dose: 5 g once daily on non-dialysis days
- For severe hyperkalemia (K+ >6.5 mEq/L): Consider 10 g once daily on non-dialysis days
- Maintenance dose range: 5-15 g once daily on non-dialysis days
- Monitoring: Assess serum potassium after one week of initiation or dose adjustment
- Dose adjustment: Based on pre-dialysis serum potassium value after the long inter-dialytic interval
Patients with CKD Not on Dialysis
- No specific dose adjustment is required for non-dialysis CKD patients
- Standard dosing applies: 10 g three times daily for initial treatment (up to 48 hours), followed by 10 g once daily for maintenance
- Dose can be adjusted based on serum potassium levels (5-15 g daily)
Monitoring Recommendations
- Monitor serum potassium regularly to guide dose adjustments
- For hemodialysis patients: Discontinue or decrease dose if:
- Serum potassium falls below desired target range based on pre-dialysis value
- Patient develops clinically significant hypokalemia 1
- Consider more frequent monitoring in patients with fluctuating renal function
Clinical Considerations
Efficacy in Renal Impairment
Research shows that sodium zirconium cyclosilicate effectively corrects hyperkalemia regardless of CKD stage. A post-hoc analysis demonstrated that 82% of patients with eGFR <30 mL/min/1.73 m² achieved normokalaemia within 24 hours, and 100% within 72 hours 2.
Special Precautions
Edema risk: Each 5 g dose contains approximately 400 mg of sodium
- Monitor for signs of edema, particularly in patients prone to fluid overload
- Adjust dietary sodium if appropriate
- Consider increasing diuretic doses as needed 1
Hypokalemia risk: Patients on hemodialysis may be prone to acute illness that increases hypokalemia risk
- Consider adjusting dose based on potassium levels during acute illness 1
Administration Considerations
- Administer as a suspension in water
- Other oral medications should be given at least 2 hours before or 2 hours after Lokelma 1
Advantages Over Other Potassium Binders
Sodium zirconium cyclosilicate has shown more rapid potassium reduction compared to calcium polystyrene sulfonate, particularly in patients with moderate to severe hyperkalemia who need rapid potassium reduction 3. It also has better palatability than older agents like sodium polystyrene sulfonate, which may improve adherence 4.
The KDIGO guidelines note that patiromer and sodium zirconium cyclosilicate have advantages over sodium polystyrene sulfonate as they don't need to be administered three times daily, increasing medication adherence and reducing potential drug interactions 4.