What is the recommended daily dose of Lokelma (sodium zirconium cyclosilicate) for treating hyperkalemia?

Lokelma Daily Dosing for Hyperkalemia

The FDA-approved dosing of Lokelma is 10 g three times daily for up to 48 hours for initial treatment, followed by 10 g once daily for maintenance, with dose adjustments ranging from 5 g every other day to 15 g daily based on serum potassium monitoring. 1

Initial Treatment Phase (Acute Hyperkalemia)

For patients with hyperkalemia requiring initial correction, administer 10 g of Lokelma three times daily (total 30 g/day) for up to 48 hours. 1 This regimen consistently produces a mean serum potassium reduction of 1.1 mEq/L, with levels typically decreasing from 5.6 mEq/L to 4.5 mEq/L within 48 hours. 2

Onset and Efficacy Expectations

• Lokelma begins lowering potassium within 1 hour of administration, making it significantly faster than patiromer (7 hours). 2
• 84% of patients achieve normokalaemia (3.5-5.0 mEq/L) within 24 hours, and 98% achieve it by 48 hours with the three-times-daily dosing regimen. 3
• The median time to potassium normalization is 2.2 hours. 3

Maintenance Treatment Phase

After achieving normokalaemia, transition to 10 g once daily as the standard maintenance dose. 1 This dose maintains 90% of patients in the normokalemic range over 28 days. 2

Dose Titration Algorithm

Monitor serum potassium levels and adjust the maintenance dose in 5 g increments at intervals of 1 week or longer:

• If potassium remains elevated: Increase dose up to maximum of 15 g daily 1
• If potassium falls below target range: Decrease dose or discontinue 1
• Maintenance dose range: 5 g every other day to 15 g daily 1

The dose-dependent response shows exponential efficacy, with 10 g dosing producing a 0.30% rate of change in serum potassium—the most effective studied dose. 2

Special Population: Chronic Hemodialysis Patients

For patients on chronic hemodialysis, administer Lokelma only on non-dialysis days:

• Standard starting dose: 5 g once daily on non-dialysis days 1
• For severe hyperkalemia (>6.5 mEq/L): Consider 10 g once daily on non-dialysis days 1
• Dose range: 5 g to 15 g once daily on non-dialysis days 1
• Monitor pre-dialysis potassium after the long inter-dialytic interval and adjust accordingly 1

Administration Guidelines

Administer other oral medications at least 2 hours before or 2 hours after Lokelma to avoid potential binding interactions. 1

Reconstitution instructions:

• Empty entire packet contents into approximately 3 tablespoons of water 1
• Stir well and drink immediately 1
• Rinse glass with additional water if powder remains to ensure complete dose administration 1

Safety Monitoring and Precautions

Sodium Content Warning

Each 5 g dose contains approximately 400 mg of sodium (the 10 g dose therefore contains ~800 mg sodium). 2, 1 Monitor for edema, particularly in patients who should restrict sodium intake or are prone to fluid overload (heart failure, renal disease). 1

Edema Risk by Dose

• 10 g daily: Edema occurs in approximately 6% of patients 2
• 15 g daily: Edema occurs in approximately 14% of patients 2, 3
• Edema is generally mild to moderate in severity 1

Hypokalemia Risk

Monitor serum potassium regularly to avoid overcorrection:

• Hypokalemia developed in 10% of patients on 10 g daily and 11% on 15 g daily in clinical trials 3
• No hypokalemia occurred with 5 g daily dosing 3
• Discontinue or reduce dose if potassium falls below desired target range 1

Clinical Context: Maintaining RAAS Inhibitor Therapy

Do not discontinue cardioprotective RAAS inhibitors (ACE inhibitors, ARBs) when treating hyperkalemia with Lokelma. 2 The newer potassium binders like Lokelma enable optimization of RAAS inhibitor therapy while managing hyperkalemia, which is critical for patients with heart failure, chronic kidney disease, or post-myocardial infarction. 2

Contraindications and Cautions

Avoid Lokelma in patients with:

• Severe constipation, bowel obstruction, or impaction 1
• Abnormal post-operative bowel motility disorders 1

These conditions have not been studied with Lokelma, and the medication may be ineffective or worsen gastrointestinal symptoms. 1

Long-Term Efficacy

Lokelma maintains efficacy over extended treatment periods:

• Clinical trials demonstrate sustained potassium control for up to 11-12 months 4, 5, 6
• Efficacy is consistent across all patient subgroups including chronic kidney disease, diabetes, heart failure, and those on RAAS inhibitor therapy 4
• The safety profile remains consistent over long-term use with no new safety concerns emerging 6