Can I use Veltassa (patiromer) for hyperkalemia?

Using Veltassa (Patiromer) for Hyperkalemia Management

Yes, Veltassa (patiromer) is indicated for the treatment of hyperkalemia in adults and pediatric patients ages 12 years and older, and should be considered for patients with chronic hyperkalemia despite optimized diuretic therapy and correction of metabolic acidosis. 1, 2

Indications and Limitations

• Veltassa is FDA-approved for the treatment of hyperkalemia in adults and pediatric patients ages 12 years and older 2
• Important limitation: Veltassa should not be used as an emergency treatment for life-threatening hyperkalemia due to its delayed onset of action (approximately 7 hours) 2, 3
• Patiromer is a non-absorbed potassium binder that exchanges calcium for potassium in the gastrointestinal tract, increasing fecal potassium excretion and reducing serum potassium levels 4, 5

Dosing Recommendations

• For adults, the recommended starting dose is 8.4 grams orally once daily 2
• Dose can be titrated based on serum potassium levels at 1-week or longer intervals, in increments of 8.4 grams, up to a maximum of 25.2 grams once daily 2
• For pediatric patients ages 12 years and older, the recommended starting dose is 4 grams orally once daily, with titration in increments of 4 grams 2
• Administer Veltassa at least 3 hours before or 3 hours after other oral medications to avoid potential drug interactions 2

Clinical Scenarios for Veltassa Use

• Patients with K+ levels >5.0 mEq/L to <6.5 mEq/L on maximal tolerated, guideline-recommended dose of RAASi therapy 1
• Patients with K+ levels >5.0 mEq/L to <6.5 mEq/L not on maximal tolerated, guideline-recommended dose of RAASi therapy, to enable up-titration of these beneficial medications 1
• Patients with chronic hyperkalemia despite optimized diuretic therapy and correction of metabolic acidosis 1
• Patients with chronic kidney disease and/or diabetic nephropathy with or without heart failure who have hyperkalemia 6

Efficacy and Monitoring

• In clinical trials, patiromer effectively reduced serum potassium levels and maintained normokalemia for up to 52 weeks 6
• For mild hyperkalemia (K+ 5.0-5.5 mEq/L), patiromer reduced serum potassium by 0.35-0.55 mEq/L at 4 weeks 6
• For moderate hyperkalemia (K+ 5.6-5.9 mEq/L), patiromer reduced serum potassium by 0.87-0.97 mEq/L at 4 weeks 6
• Regular monitoring of serum potassium is essential to avoid hypokalemia and guide dose adjustments 3

Adverse Effects and Precautions

• Most common adverse effects include gastrointestinal disorders (particularly constipation in 6.3% of patients) and hypomagnesemia (7.2% of patients) 1, 6
• Hypokalemia (<3.5 mEq/L) occurred in 5.6% of patients during long-term treatment 6
• Regular monitoring of serum magnesium is recommended due to risk of hypomagnesemia 3
• Avoid use in patients with severe constipation, bowel obstruction or impaction 2

Advantages Over Older Potassium Binders

• Patiromer is more palatable than sodium polystyrene sulfonate (SPS), potentially facilitating better adherence and efficacy 1
• Unlike SPS, patiromer is sodium-free, making it suitable for patients with heart failure or hypertension who require sodium restriction 4
• Patiromer has a higher potassium-binding capacity compared to other resins, including polystyrene sulfonate 5

Clinical Pearls

• When initiating patiromer, consider evaluating the patient's diet, use of supplements, salt substitutes, and concomitant medications that may contribute to hyperkalemia 1
• Patiromer can enable continuation of beneficial RAASi therapy in patients who would otherwise require dose reduction or discontinuation due to hyperkalemia 7, 4
• Prepare each dose immediately prior to administration by mixing with water or other soft foods (e.g., apple sauce, yogurt) 2
• For acute, severe hyperkalemia, sodium zirconium cyclosilicate (SZC, Lokelma) may be preferred due to its faster onset of action (1-2 hours) compared to patiromer (7 hours) 7, 3