What is the dosing regimen for Lokelma (sodium zirconium cyclosilicate) in a patient with hyperkalemia?

Lokelma (Sodium Zirconium Cyclosilicate) Dosing for Hyperkalemia with Potassium of 5.8 mEq/L

For a patient with a potassium level of 5.8 mEq/L, the recommended dosing regimen is Lokelma 10g three times daily for 48 hours, followed by maintenance therapy starting at 10g once daily with subsequent dose adjustments based on serum potassium monitoring. 1, 2

Initial Treatment Phase

• Initial dose: 10g three times daily for up to 48 hours 1, 2
• Administration:
  • Empty entire contents of packet(s) into a glass with approximately 3 tablespoons of water
  • Stir well and drink immediately
  • If powder remains, add more water, stir and drink until no powder remains 2
• Expected response:
  • Onset of action within 1 hour
  • 84% of patients achieve normal potassium within 24 hours
  • 98% of patients achieve normal potassium within 48 hours 1, 3

Maintenance Phase

• Starting maintenance dose: 10g once daily after achieving normokalemia 1, 2
• Dose adjustment:
  • Monitor serum potassium regularly (within 1 week of any dose adjustment)
  • Increase dose in 5g increments at intervals of 1 week or longer if potassium remains elevated
  • Decrease dose or discontinue if potassium falls below desired target range
  • Maintenance dose range: 5g every other day to 15g daily 2

Special Considerations

• Drug interactions: Administer other oral medications at least 2 hours before or 2 hours after Lokelma 2
• Monitoring: Check serum potassium within 2-4 hours after initial treatment and within 1 week of any dose adjustment 1
• Hemodialysis patients: Administer only on non-dialysis days, starting with 5g once daily (10g for potassium >6.5 mEq/L) 2

Potential Adverse Effects

• Edema: More common with 15g daily dosing (14% incidence) due to sodium content (400mg sodium per 5g dose) 1, 2, 3
• Hypokalemia: Risk increases with higher doses (10% with 10g daily, 11% with 15g daily) 1
• Gastrointestinal effects: Avoid use in patients with severe constipation, bowel obstruction or impaction 2

Clinical Pearls

• Lokelma has a faster onset of action (within 1 hour) compared to patiromer (7 hours) 1
• The 10g maintenance dose maintains mean serum potassium at approximately 4.5 mEq/L, while the 5g dose maintains levels at approximately 4.8 mEq/L 1
• Lokelma is not indicated for emergency treatment of life-threatening hyperkalemia due to its delayed onset of action 2
• Consider temporarily withholding Lokelma during prolonged fasting, surgery, or critical medical illness 1
• May provide added benefit for patients with metabolic acidosis due to sustained increases in serum bicarbonate 1

Remember that consistent monitoring is essential to avoid both persistent hyperkalemia and treatment-induced hypokalemia, especially when using higher maintenance doses.