What is the treatment for hyperkalemia using Veltassa (patiromer)?

Treatment of Hyperkalemia with Veltassa (Patiromer)

Veltassa (patiromer) is indicated for the treatment of hyperkalemia in adults and pediatric patients ages 12 years and older, but should not be used as an emergency treatment for life-threatening hyperkalemia due to its delayed onset of action. 1

Mechanism of Action

• Patiromer is a non-absorbed, sodium-free potassium binding polymer that exchanges calcium for potassium in the gastrointestinal tract, increasing fecal potassium excretion and reducing serum potassium levels 2
• Unlike older potassium binders, patiromer is more palatable, which facilitates adherence and efficacy, potentially leading to improved outcomes 3

Dosing and Administration

• For adults: The recommended starting dose is 8.4 grams orally once daily 1
• For pediatric patients ages 12 years and older: The recommended starting dose is 4 grams orally once daily 1
• Dose can be titrated based on serum potassium levels at 1-week or longer intervals, up to a maximum dose of 25.2 grams once daily 1
• Administer Veltassa at least 3 hours before or 3 hours after other oral medications to avoid potential drug interactions 1
• Patiromer is equally effective when taken with or without food, offering dosing flexibility 4

Preparation Instructions

• Prepare each dose immediately prior to administration 1
• Mix with water or other beverages/soft foods (e.g., apple sauce, yogurt) 1
• The powder will not dissolve completely and the mixture will look cloudy 1
• Drink immediately and add more liquid if powder remains in glass to ensure complete dose administration 1

Clinical Use Algorithm

1. Assess severity of hyperkalemia:

   • Mild: 5.0-5.9 mEq/L 5
   • Moderate: 6.0-6.4 mEq/L 5
   • Severe: ≥6.5 mEq/L 5

2. For acute, severe hyperkalemia (≥6.5 mEq/L or with ECG changes):

   • Use standard emergency treatments first (calcium, insulin/glucose, albuterol) 6, 5
   • Do not use Veltassa as emergency treatment due to its delayed onset of action 1

3. For chronic hyperkalemia management:

   • Start patiromer at recommended dose based on age 1
   • Monitor serum potassium and adjust dose as needed 1
   • Continue treatment as long as hyperkalemia risk factors persist 3

4. For patients on RAAS inhibitors with hyperkalemia:

   • For K+ levels >5.0 to <6.5 mEq/L on maximum tolerated RAAS inhibitor therapy: Initiate patiromer to maintain normokalemia 3
   • For K+ levels >5.0 to <6.5 mEq/L not on maximum tolerated RAAS inhibitor therapy: Initiate patiromer, and if K+ levels decrease to <5.0 mEq/L, up-titrate RAAS inhibitor therapy 3

Efficacy

• Clinical trials have demonstrated that patiromer effectively reduces serum potassium levels and the risk of recurrent hyperkalemia in patients with chronic kidney disease and/or diabetic nephropathy with or without heart failure 2
• Patiromer allows the majority of patients to continue receiving renin-angiotensin-aldosterone system (RAAS) inhibitors for up to 52 weeks 2
• In hemodialysis patients, patiromer has been shown to reduce serum potassium by approximately 0.5 mEq/L, with significant reductions in the proportion of patients with K+ ≥6.0 mEq/L (48% pre-patiromer vs. 22% post-patiromer) 7

Safety and Adverse Effects

• Most common adverse events are gastrointestinal disorders (diarrhea, constipation) and hypomagnesaemia 2
• Avoid use in patients with severe constipation, bowel obstruction or impaction, as patiromer may be ineffective and may worsen gastrointestinal conditions 1
• Monitor for hypomagnesemia, especially in patients with baseline low magnesium levels 4
• Contraindicated in patients with a history of hypersensitivity reaction to patiromer or any of its components 1

Important Clinical Considerations

• Patiromer should be considered in patients with chronic hyperkalemia despite optimized diuretic therapy and correction of metabolic acidosis 3
• The European Society of Cardiology recommends patiromer for patients who develop hyperkalemia while on RAAS inhibitors to enable continued use of these beneficial medications 3
• Regular monitoring of serum potassium is essential during treatment to avoid overcorrection and hypokalemia 5
• Consider a team approach for chronic hyperkalemia management, involving specialists (cardiologists, nephrologists), primary care physicians, and other healthcare professionals 3