Recommended Dosing of Potassium Binders for Hyperkalemia Management
For managing hyperkalemia, patiromer (Veltassa) should be started at 8.4 g once daily for adults and adjusted by 8.4 g weekly as needed, while sodium zirconium cyclosilicate (Lokelma) should be initiated at 10 g three times daily for up to 48 hours followed by 10 g once daily maintenance dosing. 1, 2
Initial Treatment Dosing
Sodium Zirconium Cyclosilicate (Lokelma)
- The recommended starting dose is 10 g administered three times daily for up to 48 hours for initial treatment of hyperkalemia 2
- Onset of action begins within 1 hour of administration, making it suitable for more rapid potassium reduction 3
- In clinical trials, this initial dosing regimen consistently demonstrated a mean reduction of 1.1 mEq/L in serum potassium 3
Patiromer (Veltassa)
- For adults, the recommended starting dose is 8.4 g administered orally once daily 1
- For pediatric patients 12-17 years of age, the recommended starting dose is 4 g once daily 1
- Patiromer has a slower onset of action (approximately 7 hours) compared to SZC (1 hour) 3
Maintenance Dosing
Sodium Zirconium Cyclosilicate (Lokelma)
- For continued treatment, the recommended maintenance dose is 10 g once daily 2
- Dose adjustments should be made at intervals of 1 week or longer in increments of 5 g 2
- The recommended maintenance dose range is from 5 g every other day to 15 g daily 2
- For patients on chronic hemodialysis, administer only on non-dialysis days, with a starting dose of 5 g once daily 2
Patiromer (Veltassa)
- Adjust dose by 8.4 g daily as needed at one-week intervals to obtain desired serum potassium target range 1
- For pediatric patients 12-17 years, adjust dose by 4 g daily at one-week intervals as needed 1
- The maximum recommended dosage in adults and pediatric patients older than 12 years is 25.2 g once daily 1
Efficacy and Dose-Response Relationship
Sodium Zirconium Cyclosilicate (Lokelma)
- Clinical trials have demonstrated a dose-dependent response with SZC, with increasing effectiveness at higher doses 3
- Maintenance doses of 5 g, 10 g, and 15 g once daily effectively maintained normal potassium levels (3.5-5.0 mEq/L) for up to 28 days 3
- In the HARMONIZE trial, SZC demonstrated a mean change of 1.1 mEq/L in serum potassium reduction with the standard initial treatment protocol 3
Patiromer (Veltassa)
- In the AMETHYST-DN trial, different starting doses showed varying efficacy based on baseline potassium levels 4:
- For mild hyperkalemia (K+ 5.0-5.5 mEq/L): 4.2 g BID reduced K+ by 0.35 mEq/L, 8.4 g BID by 0.51 mEq/L, and 12.6 g BID by 0.55 mEq/L
- For moderate hyperkalemia (K+ 5.5-6.0 mEq/L): 8.4 g BID reduced K+ by 0.87 mEq/L, 12.6 g BID by 0.97 mEq/L, and 16.8 g BID by 0.92 mEq/L 4
Administration Considerations
Sodium Zirconium Cyclosilicate (Lokelma)
- Empty packet contents into a drinking glass containing approximately 3 tablespoons of water, stir well and drink immediately 2
- Other oral medications should be administered at least 2 hours before or 2 hours after SZC 2
Patiromer (Veltassa)
- Take other orally administered drugs at least 3 hours before or 3 hours after patiromer 1
- This separation is important as patiromer may bind to other oral medications, potentially reducing their absorption 1
Common Side Effects and Monitoring
Sodium Zirconium Cyclosilicate (Lokelma)
- Most common adverse effects include mild to moderate edema (particularly with higher doses) and hypokalemia 5, 3
- Each 5 g dose contains approximately 400 mg of sodium, requiring caution in patients who should restrict sodium intake 2
- Monitor for signs of edema, particularly in patients prone to fluid overload 2
Patiromer (Veltassa)
- Most common adverse reactions (≥2%) include constipation, hypomagnesemia, diarrhea, nausea, abdominal discomfort, and flatulence 1
- Regular monitoring of serum magnesium is recommended, as hypomagnesemia occurred in 7.2% of patients in clinical trials 5
- Monitor for hypokalemia, which occurred in 5.6% of patients during long-term treatment 5