What is the normal dose of Lokelma (sodium zirconium cyclosilicate) for hyperkalemia in patients with impaired renal function?

Lokelma Dosing for Hyperkalemia in Renal Failure

For hyperkalemia in patients with renal impairment, the standard Lokelma (sodium zirconium cyclosilicate) dose is 10 g three times daily for up to 48 hours, followed by 10 g once daily for maintenance, with dose adjustments based on serum potassium monitoring. 1

Initial Treatment Phase

• Administer 10 g orally three times daily for up to 48 hours to rapidly lower serum potassium levels in patients with hyperkalemia, regardless of renal function status 1, 2
• This regimen produces a mean serum potassium reduction of approximately 1.1 mEq/L, with levels decreasing from 5.6 mEq/L at baseline to 4.5 mEq/L at 48 hours 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 4, 3
• The mechanism involves preferential exchange of hydrogen and sodium for potassium ions throughout the gastrointestinal tract, increasing fecal potassium excretion 2

Maintenance Treatment Phase

• After achieving normokalemia, continue with 10 g once daily as the standard maintenance dose 1
• Monitor serum potassium levels and adjust the dose at intervals of 1 week or longer in increments of 5 g based on serum potassium levels and desired target range 1
• The maintenance dose range is 5 g every other day to 15 g daily, with clinical trials demonstrating that 10 g once daily maintains normokalemia in 90% of patients over 28 days 5, 3
• Decrease the dose or discontinue if serum potassium falls below the desired target range 1

Special Considerations for Renal Failure Patients

Chronic Kidney Disease (Non-Dialysis)

• Lokelma is equally effective across all stages of CKD, with 82% of patients with eGFR <30 mL/min/1.73 m² achieving normokalaemia within 24 hours during the correction phase 6
• Long-term efficacy is maintained regardless of CKD stage, with 82% of patients with severe CKD (eGFR <30) maintaining normokalemia at Day 365 6
• The dose-dependent response shows a 0.30% exponential rate of change in serum potassium with 10 g dosing, which is the most effective studied dose 5

Chronic Hemodialysis Patients

• For patients on chronic hemodialysis, administer Lokelma only on non-dialysis days 1
• Start with 5 g once daily on non-dialysis days as the recommended initial dose 1
• Consider 10 g once daily on non-dialysis days if serum potassium is greater than 6.5 mEq/L 1
• Monitor pre-dialysis serum potassium after the long inter-dialytic interval and adjust dose accordingly, with maintenance doses ranging from 5 g to 15 g once daily on non-dialysis days 1

Monitoring Protocol

• Check serum potassium within 2-4 weeks after initiation or dose adjustment to ensure appropriate response and avoid overcorrection 5
• During the initial 48-hour correction phase, potassium levels should be monitored to assess response 3
• After achieving stable maintenance dosing, continue monitoring at regular intervals based on clinical stability and risk factors 1
• Discontinue or decrease the dose if serum potassium falls below the desired target range or if clinically significant hypokalemia develops 1

Safety Considerations

• Each 5 g dose contains approximately 400 mg of sodium, requiring monitoring for edema, particularly in patients who should restrict sodium intake or are prone to fluid overload 1
• Edema occurs in approximately 6% of patients on 10 g daily and 14% on 15 g daily, and is generally mild to moderate in severity 4, 3
• Hypokalemia developed in 10% of patients receiving 10 g daily in clinical trials, emphasizing the importance of monitoring 3
• The reversible decrease in eGFR on initiation is generally not an indication to discontinue therapy 5

Critical Advantages in Renal Failure

• Lokelma enables continuation of cardioprotective RAAS inhibitors (ACE inhibitors, ARBs, mineralocorticoid receptor antagonists) in patients with CKD and hyperkalemia, which is crucial for slowing CKD progression and improving cardiovascular outcomes 7, 6
• Unlike sodium polystyrene sulfonate (SPS), Lokelma has a more favorable safety profile without serious gastrointestinal adverse events and does not cause hypocalcemia or hypomagnesemia 5
• The selectivity for potassium and faster onset of action (1 hour vs. 7 hours for patiromer) make it particularly useful in managing hyperkalemia in renal failure patients 4, 5

Important Caveats

• Lokelma should not be used as emergency treatment for life-threatening hyperkalemia due to its delayed onset of action; use IV calcium gluconate, insulin/glucose, or beta-agonists for acute management 1
• Avoid use in patients with severe constipation, bowel obstruction, or impaction, as Lokelma has not been studied in these conditions and may be ineffective or worsen gastrointestinal symptoms 1
• Administer other oral medications at least 2 hours before or 2 hours after Lokelma to avoid potential binding interactions 1