What is the recommended dosing for Lokelma (sodium zirconium cyclosilicate) in treating hyperkalemia?

Lokelma Dosing for Hyperkalemia

Initial Treatment Phase

For initial treatment of hyperkalemia, administer Lokelma 10 g three times daily for up to 48 hours. 1

• This dosing regimen achieves a mean serum potassium reduction of 1.1 mEq/L, typically lowering levels from 5.6 mEq/L to 4.5 mEq/L within 48 hours 2, 3
• Onset of action begins within 1 hour of the first dose, with 84% of patients achieving normokalemia (3.5-5.0 mEq/L) by 24 hours and 98% by 48 hours 2, 3
• The medication should be administered as an oral suspension in water, with other oral medications given at least 2 hours before or after Lokelma to avoid binding interactions 1

Important limitation: Do not use Lokelma as emergency treatment for life-threatening hyperkalemia due to its delayed onset compared to acute interventions like insulin/glucose or calcium 1

Maintenance Treatment Phase

After achieving normokalemia, continue with Lokelma 10 g once daily as the standard maintenance dose. 1

• The maintenance dose range is 5 g every other day to 15 g daily, adjusted based on serum potassium monitoring 1
• In clinical trials, 90% of patients maintained normokalemia on 10 g daily dosing over 28 days 2
• Titrate the dose upward in 5 g increments at intervals of 1 week or longer based on serum potassium levels 1
• Decrease or discontinue if serum potassium falls below the desired target range 1

Special Population: Chronic Hemodialysis

For patients on chronic hemodialysis, start with 5 g once daily on non-dialysis days only. 1

• Consider starting with 10 g once daily on non-dialysis days if serum potassium is greater than 6.5 mEq/L 1
• Monitor pre-dialysis potassium after the long inter-dialytic interval and adjust dosing accordingly 1
• The maintenance dose range remains 5 g to 15 g once daily on non-dialysis days 1

Monitoring and Safety Considerations

Monitor serum potassium regularly to avoid hypokalemia, particularly with higher doses. 1

• Edema is the most common adverse effect, occurring in approximately 6% of patients on 10 g daily and 14% on 15 g daily 2
• Each 5 g dose contains approximately 400 mg of sodium; monitor for signs of edema, especially in patients who should restrict sodium intake or are prone to fluid overload 1
• Hypokalemia developed in 10% of patients receiving 10 g daily and 11% receiving 15 g daily in clinical trials 3

Critical Clinical Context

Do not discontinue RAAS inhibitors (ACE inhibitors, ARBs) when treating hyperkalemia with Lokelma. 2

• Lokelma enables optimization of cardioprotective RAAS inhibitor therapy while managing hyperkalemia 2, 4
• The medication maintains efficacy across all patient subgroups including chronic kidney disease, diabetes, heart failure, and those on RAAS inhibitor therapy 5, 6

Contraindications and Precautions

Avoid Lokelma in patients with severe constipation, bowel obstruction, or impaction. 1

• The medication has not been studied in these conditions and may be ineffective or worsen gastrointestinal symptoms 1
• Abnormal post-operative bowel motility disorders are also contraindications 1