Is it okay to give Lokelma (sodium zirconium cyclosilicate) to a patient with hypotension (low blood pressure)?

Administering Lokelma (Sodium Zirconium Cyclosilicate) in Patients with Hypotension

Lokelma should be used with caution in patients with hypotension due to its sodium content and potential risk of worsening heart failure and edema, particularly at higher doses. 1

Mechanism and Concerns

Sodium zirconium cyclosilicate (SZC/Lokelma) is a non-absorbed cation exchanger that selectively binds potassium in the intestinal tract, exchanging sodium for potassium ions. This mechanism effectively lowers serum potassium but introduces sodium into the system, which may:

• Contribute to fluid retention
• Potentially worsen hypotension in volume-depleted patients
• Increase risk of heart failure exacerbation in susceptible patients

Risk Assessment

Recent evidence shows concerning safety signals when comparing SZC to patiromer (a calcium-based potassium binder):

• Higher incidence of edema with SZC, particularly at higher doses (14% with 15g dose) 2
• Increased risk of hospitalizations for heart failure (HR 1.373; 95% CI, 1.337-1.410) 3
• Higher risk of major edema encounters (HR 1.330; 95% CI, 1.298-1.363) 3

Clinical Decision Algorithm

1. Assess severity of hypotension and hyperkalemia:

   • If severe hyperkalemia with life-threatening ECG changes: Consider alternative urgent treatments (insulin/glucose, calcium)
   • If moderate hyperkalemia without urgent features: Proceed with caution

2. Evaluate volume status:

   • If patient appears volume depleted: Address volume status before administering Lokelma
   • If euvolemic: Proceed with lowest effective dose

3. Consider cardiac function:

   • In patients with heart failure: Higher vigilance required; consider patiromer as alternative 1, 3
   • In patients with normal cardiac function: Lower risk but still monitor

4. Dosing considerations:

   • Start with lowest effective dose (5g) to minimize sodium load
   • Monitor blood pressure closely after administration
   • Avoid 15g dose in hypotensive patients due to higher edema risk (14%) 2

Monitoring Recommendations

• Check blood pressure before and within 1-2 hours after administration
• Monitor for signs of worsening edema
• Follow serum potassium to ensure efficacy
• Consider daily weights in susceptible patients

Alternative Approaches

For patients with significant hypotension and hyperkalemia:

1. Consider patiromer as an alternative potassium binder (calcium-based, not sodium-based) 1, 3
2. Address underlying causes of hypotension before administering Lokelma
3. In acute settings with severe hypotension, prioritize hemodynamic stabilization with vasopressors if needed 4

Clinical Pitfalls to Avoid

• Administering high doses (10-15g) to patients with heart failure and hypotension
• Failing to monitor for fluid retention after administration
• Overlooking the sodium content when calculating total daily sodium intake
• Using in patients with severe heart failure without close monitoring

The Mayo Clinic Proceedings guideline on hyperkalemia management notes that while SZC is effective for hyperkalemia, its sodium content requires careful consideration in patients with conditions where sodium and fluid retention are concerns 1.