From the Guidelines
Oral medications for chronic hyperkalemia include patiromer (Veltassa) and sodium zirconium cyclosilicate (Lokelma), with patiromer being a preferred option due to its efficacy and safety profile as shown in recent studies 1. When managing chronic hyperkalemia, it is essential to consider the potential benefits and risks of each medication.
- Patiromer is usually started at 8.4g once daily and can be titrated up to 25.2g daily; it binds potassium in the gastrointestinal tract and should be taken with food, separated from other medications by at least 3 hours 1.
- Sodium zirconium cyclosilicate begins with 10g three times daily for 48 hours, followed by 5-10g once daily maintenance; it works by trapping potassium in the intestinal tract 1. These medications should be used alongside dietary potassium restriction and optimization of contributing medications like renin-angiotensin-aldosterone system inhibitors. Regular monitoring of serum potassium levels is essential, as is addressing the underlying cause of hyperkalemia, which often involves kidney dysfunction, medication effects, or endocrine disorders 1. The use of sodium polystyrene sulfonate has fallen out of favor due to potential gastrointestinal side effects, including colonic necrosis, and is not recommended as a first-line treatment for chronic hyperkalemia 1. In patients with heart failure, patiromer has been shown to be effective in reducing potassium levels and allowing for increased doses of spironolactone, a crucial medication for these patients 1. Overall, the choice of oral medication for chronic hyperkalemia should be based on the individual patient's needs and medical history, with a focus on minimizing risks and optimizing efficacy.
From the FDA Drug Label
LOKELMA is indicated for the treatment of hyperkalemia in adults. For initial treatment of hyperkalemia, the recommended dose of LOKELMA is 10 g administered three times a day for up to 48 hours. For continued treatment, the recommended dose is 10 g once daily.
The mean daily doses of Veltassa were 13 grams and 21 grams in patients with serum potassium of 5.1 to < 5.5 mEq/L and 5.5 to < 6.5 mEq/L, respectively.
The oral medication options for managing chronic hyperkalemia are:
- Sodium zirconium cyclosilicate (LOKELMA): initial dose of 10 g three times a day for up to 48 hours, then 10 g once daily for continued treatment 2
- Patiromer (Veltassa): mean daily doses of 13 grams and 21 grams in patients with serum potassium of 5.1 to < 5.5 mEq/L and 5.5 to < 6.5 mEq/L, respectively 3
From the Research
Oral Medication Options for Managing Chronic Hyperkalemia
The following oral medications are available for managing chronic hyperkalemia:
- Patiromer: a potassium-binding medication that facilitates fecal excretion of potassium 4, 5, 6
- Sodium zirconium cyclosilicate (ZS9): a potassium-binding medication that facilitates fecal excretion of potassium 4, 5, 6
- Sodium polystyrene sulfonate (SPS): a potassium-binding medication that facilitates fecal excretion of potassium, although its use is limited due to concerns about rare GI damage and electrolyte abnormalities 4
Efficacy and Safety of Oral Medications
Studies have demonstrated the efficacy and safety of patiromer and sodium zirconium cyclosilicate in managing chronic hyperkalemia:
- Patiromer and ZS9 have been shown to have a dose-dependent potassium-lowering effect and can be used to initiate, maintain, or titrate renin-angiotensin-aldosterone system inhibitors 4
- Both medications have been associated with adverse GI effects, although they are less frequent with ZS9 4
- Electrolyte abnormalities have been reported with patiromer and SPS, while urinary tract infections, edema, and corrected QT-interval prolongations have been reported with ZS9 4
Comparison of Oral Medications
A study comparing the effectiveness of patiromer and sodium zirconium cyclosilicate in reducing serum potassium levels found no significant difference between the two medications 7
- Both medications were effective in reducing serum potassium levels, although the study was conducted in the setting of acute hyperkalemia rather than chronic hyperkalemia 7