Lokelma (Sodium Zirconium Cyclosilicate) for Hyperkalemia
Dosing Regimen
For acute correction of hyperkalemia, initiate Lokelma 10 g three times daily for up to 48 hours, then transition to 10 g once daily for maintenance, adjusting by 5 g increments based on serum potassium levels. 1
Initial Correction Phase
- Standard dose: 10 g orally three times daily for up to 48 hours 1
- Expected effect: Mean serum potassium reduction of approximately 1.1 mEq/L over 48 hours 2, 3
- Onset of action: Significant reductions begin within 1 hour, with mean reduction of 0.72 mEq/L within 2 hours when combined with insulin/glucose 4
- Normalization rate: 84% of patients achieve normokalemia (3.5-5.0 mEq/L) within 24 hours, and 98% within 48 hours 5
Maintenance Phase
- Starting dose: 10 g once daily after achieving normokalemia 1
- Dose range: 5 g every other day to 15 g daily, adjusted at weekly intervals based on serum potassium 1
- Titration: Increase or decrease in 5 g increments to maintain target potassium range 1
- Long-term efficacy: 93% of patients maintained mean serum potassium ≤5.1 mEq/L for up to 11 months 2
Special Population: Hemodialysis Patients
- Dosing schedule: Administer only on non-dialysis days 1
- Starting dose: 5 g once daily on non-dialysis days 1
- Higher starting dose: Consider 10 g once daily for serum potassium >6.5 mEq/L 1
- Monitoring: Assess pre-dialysis potassium after the long interdialytic interval 1
Administration Instructions
Administer other oral medications at least 2 hours before or 2 hours after Lokelma to avoid drug binding and reduced absorption. 1
- Mix entire packet contents in approximately 3 tablespoons of water 1
- Stir well and drink immediately 1
- Repeat with additional water until no powder remains 1
- Lokelma can bind medications throughout the GI tract, reducing their absorption 3, 4
Critical Safety Considerations
Not for Emergency Use
Lokelma should NOT be used as emergency treatment for life-threatening hyperkalemia due to delayed onset of action. 1
- For life-threatening hyperkalemia, use insulin/glucose, beta-agonists, or dialysis first 3, 4
- Lokelma's onset begins at 1-2 hours, making it unsuitable for immediate life-threatening situations 3
Edema Risk
- Sodium content: Each 5 g dose contains approximately 400 mg sodium; 10 g dose contains 1200 mg during correction phase 3, 1
- Dose-dependent edema: 2% with 5 g daily, 6% with 10 g daily, 14% with 15 g daily 3, 5
- Monitor closely in patients requiring sodium restriction or prone to fluid overload 1
Hypokalemia Risk
- Occurs in approximately 10-11% of patients on 10-15 g daily maintenance doses 5
- Monitor serum potassium regularly and reduce dose if levels fall below target range 1
- Particularly important in hemodialysis patients—discontinue if clinically significant hypokalemia develops 1
Gastrointestinal Considerations
- Avoid in severe constipation, bowel obstruction, or impaction as Lokelma has not been studied in these conditions and may worsen symptoms 1
- Most common adverse effects: constipation, diarrhea, nausea 3
- Unlike sodium polystyrene sulfonate (SPS), Lokelma has not been associated with intestinal necrosis in clinical trials 6
Mechanism and Advantages
- Works throughout the entire GI tract (small and large intestines), not just the colon 6
- Selectively binds potassium with high specificity 7
- Significantly faster onset than patiromer (1 hour vs. 7 hours) 4
- No serious adverse events reported in randomized trials 2, 6
- May provide added benefit of sustained increases in serum bicarbonate for patients with metabolic acidosis 2, 8
Monitoring Parameters
- Check serum potassium after 48 hours of correction phase 1
- During maintenance, monitor at weekly intervals after dose adjustments 1
- For hemodialysis patients, assess after one week of initiation or dose change 1
- Monitor for signs of edema, particularly in high-risk patients 1
- Watch for hypokalemia, especially at higher maintenance doses 5