What is the recommended dose and frequency of Lokelma (sodium zirconium cyclosilicate) for a patient with hyperkalemia?

Lokelma Dosing for Potassium 5.8 mEq/L

For a potassium level of 5.8 mEq/L, initiate Lokelma 10 g three times daily for up to 48 hours, then transition to 10 g once daily for maintenance. 1

Initial Treatment Phase (First 48 Hours)

• Administer 10 g orally three times daily mixed in approximately 3 tablespoons of water for up to 48 hours 1
• This regimen achieves a mean potassium reduction of 1.1 mEq/L, typically lowering your patient's level from 5.8 mEq/L to approximately 4.7 mEq/L 2, 3
• Onset of action begins within 1 hour, with 84% of patients achieving normokalemia (3.5-5.0 mEq/L) by 24 hours and 98% by 48 hours 2, 3
• The median time to potassium normalization is 2.2 hours 3

Maintenance Phase (After 48 Hours)

• Transition to 10 g once daily after the initial 48-hour correction phase 1
• Monitor serum potassium and adjust the dose based on levels, with the maintenance dose range being 5 g every other day to 15 g daily 1
• Titrate in 5 g increments at intervals of 1 week or longer based on potassium levels 1
• In clinical trials, 90% of patients maintained normokalemia on 10 g daily dosing over 28 days 4, 3

Administration Instructions

• Separate other oral medications by at least 2 hours before or after Lokelma to avoid potential binding interactions 1
• Empty the entire packet contents into a glass with 3 tablespoons of water, stir well, and drink immediately 1
• If powder remains, add more water and repeat until the entire dose is consumed 1

Monitoring Protocol

• Check potassium within 24-48 hours after initiating therapy to assess response 3
• During maintenance, monitor potassium weekly for the first month, then monthly for 3 months, then every 3 months thereafter 5
• Discontinue or reduce dose if potassium falls below 3.5 mEq/L to avoid hypokalemia 1

Expected Outcomes and Safety

• The dose-dependent response shows 0.30% exponential rate of change with 10 g dosing, which is the most effective studied dose 4, 2
• Edema is the most common adverse effect, occurring in approximately 6% of patients on 10 g daily (compared to 14% on 15 g daily) 4, 3
• Each 5 g dose contains approximately 400 mg of sodium, so monitor for fluid retention, particularly in patients with heart failure or CKD 1
• Hypokalemia developed in 10% of patients on 10 g daily in clinical trials, emphasizing the need for regular monitoring 3

Clinical Context for Your Patient

• At 5.8 mEq/L, this represents moderate hyperkalemia that warrants treatment but is not immediately life-threatening 4
• Obtain an ECG to assess for cardiac conduction abnormalities, even though the patient may be asymptomatic 5
• Do not discontinue RAAS inhibitors if the patient is taking them; instead, manage the hyperkalemia with Lokelma while maintaining cardioprotective therapy 4
• Implement dietary potassium restriction to <3 g/day concurrently with Lokelma therapy 5

Common Pitfalls to Avoid

• Do not use Lokelma as emergency treatment for life-threatening hyperkalemia (>6.5 mEq/L with ECG changes) due to its delayed onset compared to insulin/glucose or dialysis 1
• Avoid use in patients with severe constipation or bowel obstruction, as Lokelma has not been studied in these populations and may worsen gastrointestinal conditions 1
• Do not prematurely discontinue cardioprotective medications like ACE inhibitors or ARBs; the newer potassium binders like Lokelma enable optimization of RAAS inhibitor therapy 4