What is the recommended treatment for hyperkalemia using Lokelma (sodium zirconium cyclosilicate)?

Lokelma (Sodium Zirconium Cyclosilicate) for Hyperkalemia Treatment

For initial treatment of hyperkalemia, start Lokelma 10 g three times daily for up to 48 hours, then transition to 10 g once daily for maintenance, adjusting the dose by 5 g increments based on serum potassium levels (target range 3.5-5.0 mEq/L). 1

Initial Correction Phase Dosing

• Administer 10 g three times daily for up to 48 hours to rapidly lower serum potassium 1
• Expect a mean potassium reduction of approximately 1.1 mEq/L over 48 hours 2, 3
• 84% of patients achieve normokalaemia within 24 hours, and 98% within 48 hours 4
• The median time to potassium normalization is 2.2 hours, though onset begins at 1-2 hours 3, 4

Maintenance Phase Dosing

• Start with 10 g once daily after the correction phase 1
• Monitor serum potassium and adjust dose at 1-week intervals or longer 1
• Titrate in 5 g increments (range: 5 g every other day to 15 g daily) based on potassium levels 1
• Decrease or discontinue if serum potassium falls below the desired target range 1

Maintenance Efficacy Data

• During days 8-29 of maintenance therapy, mean serum potassium levels were 4.8 mEq/L with 5 g daily, 4.5 mEq/L with 10 g daily, and 4.4 mEq/L with 15 g daily (all significantly lower than placebo at 5.1 mEq/L) 2
• 93% of patients maintained mean serum potassium ≤5.1 mEq/L across days 8-337 in long-term studies 2

Special Population: Hemodialysis Patients

• Administer only on non-dialysis days 1
• Start with 5 g once daily on non-dialysis days 1
• Consider 10 g once daily on non-dialysis days if serum potassium is >6.5 mEq/L 1
• Adjust dose based on pre-dialysis potassium after the long interdialytic interval 1
• Assess serum potassium one week after initiation or dose adjustment 1

Critical Limitation: Not for Emergency Use

Do not use Lokelma as emergency treatment for life-threatening hyperkalemia due to its delayed onset of action 3, 1

• For life-threatening hyperkalemia, use insulin/glucose, beta-agonists, or dialysis first 3
• Lokelma's onset is 1-2 hours, making it unsuitable for acute cardiac arrhythmias requiring immediate intervention 3

Administration Instructions

• Mix entire packet contents in approximately 3 tablespoons of water 1
• Stir well and drink immediately 1
• If powder remains, add more water, stir, and drink until no powder remains 1
• Separate from other oral medications by at least 2 hours (before or after) because Lokelma can bind medications throughout the GI tract and reduce their absorption 3, 1

Adverse Effects and Monitoring

Edema (Dose-Dependent)

• Incidence increases with dose: 2% with 5 g, 6% with 10 g, and 14% with 15 g daily 3, 4
• Each 5 g dose contains 400 mg of sodium (10 g TID during correction = 1200 mg sodium per dose; maintenance 5-15 g daily = 400-1200 mg sodium daily) 3, 5, 1
• Monitor for peripheral edema, particularly with maintenance doses ≥10 g daily 5, 1
• Exercise caution in patients who should restrict sodium intake or are prone to fluid overload 1

Gastrointestinal Effects

• Most common adverse effects are constipation, diarrhea, and nausea (mild to moderate severity) 3, 6, 5
• Unlike sodium polystyrene sulfonate (SPS), Lokelma has not been associated with intestinal necrosis in clinical trials 6
• No serious gastrointestinal adverse events have been reported in randomized trials 2, 6

Hypokalemia

• Hypokalemia occurred in 10% of patients on 10 g daily and 11% on 15 g daily in maintenance trials 4
• In hemodialysis patients, discontinue or decrease dose if potassium falls below target range or clinically significant hypokalemia develops 1

Metabolic Effects

• Sustained increases in serum bicarbonate have been observed, which may benefit patients with metabolic acidosis 2

Contraindications and Precautions

• No absolute contraindications 1
• Avoid in patients with severe constipation, bowel obstruction, or impaction (including abnormal post-operative bowel motility disorders) as Lokelma has not been studied in these conditions and may be ineffective or worsen GI symptoms 1

Mechanism of Action

• Lokelma is a selective potassium binder that works throughout both the small and large intestines (not just the colon like older agents) 6
• It exchanges sodium and hydrogen ions for potassium, increasing fecal potassium excretion 6, 5
• The larger surface area of action may contribute to its rapid onset compared to older potassium binders 6

Imaging Consideration

• Lokelma has radio-opaque properties and may appear similar to an imaging agent during abdominal X-ray procedures 1