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

Lokelma (Sodium Zirconium Cyclosilicate) for Hyperkalemia Treatment

Dosing Regimen

For initial correction of hyperkalemia, administer Lokelma 10 g three times daily for up to 48 hours, then transition to 10 g once daily for maintenance, adjusting the dose between 5-15 g daily based on serum potassium levels. 1

Correction Phase (First 48 Hours)

• Standard dose: 10 g three times daily for up to 48 hours 1
• Expected efficacy: Mean serum potassium reduction of approximately 1.1 mEq/L over 48 hours 2, 3, 4
• 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 2, 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 (After Correction)

• Starting dose: 10 g once daily 1
• Dose range: 5-15 g once daily, adjusted at weekly intervals in 5 g increments based on serum potassium levels 1
• Long-term efficacy: 93% of patients maintain serum potassium ≤5.1 mEq/L for up to 11 months 2
• Discontinue or reduce dose if serum potassium falls below target range 1

Special Population: Chronic Hemodialysis Patients

• 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 on non-dialysis days if serum potassium >6.5 mEq/L 1
• Dose range: 5-15 g once daily on non-dialysis days 1
• Monitor: Pre-dialysis serum potassium after the long inter-dialytic interval 1

Critical Limitations and Safety Considerations

Not for Emergency Use

Lokelma should NOT be used as emergency treatment for life-threatening hyperkalemia due to its delayed onset of action. 3, 4, 1

• For life-threatening hyperkalemia, use insulin/glucose, beta-agonists, or dialysis first 3, 4
• While onset begins at 1-2 hours, this is insufficient for emergent situations requiring immediate intervention 3, 4

Sodium Content and Edema Risk

• Each 10 g dose contains 1200 mg sodium during correction phase (three times daily dosing) 3
• Maintenance dosing contains 400-1200 mg sodium daily depending on dose 3
• Edema incidence is dose-dependent: 2% with 5 g daily, 6% with 10 g daily, and 14% with 15 g daily 3, 5
• Monitor for edema, particularly in patients requiring sodium restriction or prone to fluid overload (heart failure, CKD) 1

Drug Interactions

Administer other oral medications at least 2 hours before or 2 hours after Lokelma to avoid reduced absorption, as Lokelma can bind medications throughout the GI tract 3, 4, 1

Gastrointestinal Considerations

• Avoid use in patients with severe constipation, bowel obstruction, or impaction, as Lokelma has not been studied in these conditions and may worsen gastrointestinal status 1
• Most common adverse effects are gastrointestinal symptoms (constipation, diarrhea, nausea) and hypokalemia 2, 3, 6
• Unlike sodium polystyrene sulfonate (SPS/Kayexalate), Lokelma has not been associated with intestinal necrosis in clinical trials 6

Hypokalemia Risk

• Hypokalemia developed in 10-11% of patients receiving 10-15 g daily doses during maintenance 5
• Monitor serum potassium regularly and adjust dose accordingly 1
• In hemodialysis patients, discontinue if clinically significant hypokalemia develops 1

Mechanism and Comparative Advantages

• Works throughout the entire GI tract (both small and large intestines), unlike patiromer which works primarily in the colon 6
• Faster onset than patiromer: 1 hour versus 7 hours 4
• More palatable than Kayexalate, facilitating adherence 3
• Superior efficacy and safety profile compared to older agents like Kayexalate in chronic hyperkalemia management 3

Additional Clinical Benefits

• Sustained increases in serum bicarbonate observed with Lokelma, providing potential benefit for patients with metabolic acidosis 2, 7
• Allows continuation of RAAS inhibitors in patients with CKD, diabetes, or heart failure who develop hyperkalemia 2, 8

Monitoring and Administration

• Reconstitution: Empty entire packet contents into approximately 3 tablespoons of water, stir well, and drink immediately 1
• Monitoring frequency: Assess serum potassium after one week during initiation and after dose adjustments 1
• Radio-opaque properties: May appear as imaging agent on abdominal X-rays 1