What is the next step for managing hyperkalemia in a patient already taking Lokelma (sodium zirconium cyclosilicate) three times a day?

Management of Potassium 6.1 mEq/L on Maximum Lokelma Dosing

For a patient with potassium 6.1 mEq/L already receiving Lokelma three times daily, you should immediately stop or reduce dose of any RAAS inhibitors (ACE inhibitors, ARBs, or mineralocorticoid receptor antagonists), ensure the patient is not taking other potassium-retaining medications or supplements, and consider acute stabilization measures if ECG changes or symptoms are present. 1

Immediate Assessment and Acute Management

First, Determine Urgency

• Obtain an ECG immediately to assess for cardiac conduction abnormalities (peaked T waves, widened QRS, loss of P waves) 2
• Assess for symptoms including muscle weakness, paralysis, or palpitations that would indicate need for emergent treatment 2
• If ECG abnormalities or symptoms are present, initiate acute stabilization with intravenous calcium for cardiac membrane stabilization, followed by insulin/glucose and/or beta-agonists for transcellular shift 2

Verify True Hyperkalemia

• Rule out pseudohyperkalemia by repeating the measurement with proper blood sampling technique, as hemolysis or prolonged tourniquet time can falsely elevate results 1
• Consider arterial sampling if pseudohyperkalemia is suspected 1

Medication Review and Adjustment

RAAS Inhibitor Management

At potassium >6.0 mEq/L, current guidelines recommend stopping RAAS inhibitors entirely 1

• This includes ACE inhibitors, ARBs, and especially mineralocorticoid receptor antagonists (spironolactone, eplerenone) 1
• The ESC guidelines specifically state to stop RAASi when potassium exceeds 6.0 mEq/L 1
• If short-term cessation is necessary, minimize the duration and carefully reintroduce while monitoring potassium levels 1

Other Medication Adjustments

• Discontinue NSAIDs if the patient is taking them, as they compromise renal function and increase potassium 1
• Eliminate all potassium supplements including those in multivitamins 1
• Review all medications for potassium-sparing diuretics (amiloride, triamterene) and discontinue 1

Lokelma Dosing Considerations

Current Dosing Status

The patient is already on Lokelma 10g three times daily, which is the maximum acute dosing regimen approved for initial treatment (up to 48 hours) 3

Key Limitation

Lokelma should not be used as emergency treatment for life-threatening hyperkalemia due to delayed onset of action 3

• While Lokelma can reduce potassium within 1 hour in some patients, the patient is already on maximum dosing and still has potassium of 6.1 mEq/L 1
• This suggests either inadequate response, ongoing potassium load, or impaired renal excretion overwhelming the binder's capacity 1

Transition to Maintenance Dosing

• Once acute phase (48 hours) is complete, transition to maintenance dosing of 10-15g once daily rather than continuing three times daily dosing 3
• The FDA label specifies maintenance range of 5g every other day to 15g daily 3

Additional Potassium-Lowering Strategies

Diuretic Therapy

• Initiate or increase dose of loop diuretics (furosemide, bumetanide) to enhance renal potassium excretion 1
• This is particularly important if the patient has adequate renal function and is not anuric 1

Dietary Modification

• Implement strict low-potassium diet (<2000 mg/day) 1
• Provide specific dietary counseling on avoiding high-potassium foods (bananas, oranges, tomatoes, potatoes, beans) 2

Consider Alternative Potassium Binder

• Patiromer could be added or substituted, with onset of action approximately 7 hours 1
• Patiromer dosing starts at 8.4g once daily and can be titrated to 25.2g daily 1
• However, adding a second binder when already on maximum Lokelma dosing has limited evidence 1

Dialysis Consideration

If the patient has end-stage renal disease, severe renal impairment (eGFR <15), or ongoing potassium release despite maximal medical therapy, urgent hemodialysis should be considered 2

• Dialysis is the most effective method for rapid potassium removal when medical management fails 2
• For patients already on chronic hemodialysis, Lokelma should only be given on non-dialysis days at 5-15g once daily 3

Monitoring Plan

Short-Term Monitoring

• Recheck potassium within 24-48 hours after medication adjustments 1
• Continue ECG monitoring if initial ECG showed abnormalities 2
• Monitor for signs of edema, as each 5g dose of Lokelma contains approximately 400mg sodium 3

Long-Term Monitoring

• Once stabilized, monitor potassium weekly initially, then monthly during maintenance therapy 1
• Adjust Lokelma dose in 5g increments at intervals of 1 week or longer based on potassium levels 3
• Carefully reintroduce RAAS inhibitors once potassium is consistently <5.0 mEq/L, with close monitoring 1

Common Pitfalls to Avoid

• Do not continue three times daily Lokelma dosing beyond 48 hours as this is only approved for acute treatment 3
• Do not use sodium polystyrene sulfonate (Kayexalate) chronically due to risk of bowel necrosis, especially with sorbitol 1
• Do not delay stopping RAAS inhibitors at this potassium level, as guidelines are clear about discontinuation at >6.0 mEq/L 1
• Do not assume Lokelma alone will control potassium if the underlying cause (medication, diet, renal function) is not addressed 1
• Monitor for hypokalemia once potassium normalizes, as this occurred in 10-11% of patients on 10-15g daily maintenance dosing in trials 4