What is the initial dose of Lokelma (sodium zirconium cyclosilicate) for a patient with hyperkalemia (elevated potassium level of 6.0)?

Lokelma Dosing for Hyperkalemia with Potassium of 6.0 mEq/L

For a patient with hyperkalemia and a potassium level of 6.0 mEq/L, the recommended initial dose of Lokelma (sodium zirconium cyclosilicate) is 10 g administered three times daily for up to 48 hours, followed by maintenance dosing of 10 g once daily. 1

Initial Treatment Phase

The FDA-approved dosing for Lokelma in hyperkalemia follows a two-phase approach:

1. Acute Treatment (First 48 hours):

   • 10 g three times daily for up to 48 hours
   • Administer orally as a suspension in water
   • This dosing rapidly reduces potassium levels in patients with hyperkalemia 1

2. Administration Instructions:

   • Empty packet contents 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 1

Efficacy of Initial Treatment

Clinical evidence supports this dosing regimen:

• In phase 3 trials, SZC 10 g three times daily effectively lowered serum potassium to normal range (3.5-5.0 mmol/L) during the first 48 hours of treatment 2
• For potassium levels of 6.0 mEq/L, median time to achieve potassium ≤5.5 mEq/L was approximately 2.0 hours 3
• By 4 hours, 37.5% of patients achieved potassium ≤5.0 mEq/L, and by 48 hours, 85.0% reached this target 3

Maintenance Phase

After the initial 48-hour treatment:

• Transition to 10 g once daily for maintenance therapy 1
• Monitor serum potassium and adjust dose based on levels and desired target range
• Maintenance dose range is 5 g every other day to 15 g daily 1
• Dose adjustments should be made at intervals of 1 week or longer in increments of 5 g 1

Special Considerations

For Patients on Hemodialysis

• Administer only on non-dialysis days
• Starting dose: 5 g once daily (non-dialysis days)
• Consider 10 g once daily for potassium >6.5 mEq/L 1

Monitoring Requirements

• Check potassium and renal function within 2-3 days after initiation
• Continue monitoring monthly for at least 3 months 4
• Monitor for signs of edema, particularly in patients who should restrict sodium intake 1

Potential Adverse Effects

• Each 5 g dose contains approximately 400 mg of sodium 1
• Most common adverse effect is mild to moderate edema, particularly at higher doses (15 g daily) 1, 5
• Diarrhea has been reported as the most common gastrointestinal side effect 6
• Hypokalemia may occur, especially at higher doses (10-15 g) 5

Important Precautions

• Lokelma should not be used as emergency treatment for life-threatening hyperkalemia due to its delayed onset of action 1
• Avoid use in patients with severe constipation, bowel obstruction, or impaction 1
• Other oral medications should be administered at least 2 hours before or 2 hours after Lokelma 1

Clinical Pearls and Pitfalls

• Do not discontinue beneficial medications: Potassium binders like Lokelma can help maintain RAAS inhibitors and other beneficial medications that might otherwise be discontinued due to hyperkalemia 4
• Verify true hyperkalemia: Rule out pseudohyperkalemia (from hemolysis, poor phlebotomy technique) with repeat testing 4
• Monitor closely: Inadequate monitoring can lead to poor outcomes 4
• Consider dietary modifications: Advise patients to restrict dietary potassium intake and avoid high-potassium foods and salt substitutes containing potassium 4

Lokelma has demonstrated efficacy in rapidly normalizing potassium levels with a favorable safety profile, making it an appropriate choice for managing hyperkalemia with a potassium level of 6.0 mEq/L.