Lokelma Dosing for Potassium 5.4 mEq/L
For a potassium level of 5.4 mEq/L in this elderly patient on lisinopril and HCTZ, start Lokelma 10 g three times daily for up to 48 hours, then transition to 10 g once daily for maintenance. 1
Initial Treatment Phase (First 48 Hours)
Administer Lokelma 10 g orally three times daily for up to 48 hours to rapidly lower potassium from 5.4 mEq/L to the normal range (3.5-5.0 mEq/L). 1
Mix each dose in approximately 3 tablespoons of water, stir well, and drink immediately; repeat with additional water until no powder remains. 1
Expect median time to potassium normalization of 2.2 hours, with 84% of patients achieving normalization by 24 hours and 98% by 48 hours. 2
Administer other oral medications at least 2 hours before or 2 hours after Lokelma to avoid drug interactions. 1
Maintenance Treatment (After 48 Hours)
Transition to Lokelma 10 g once daily after the initial 48-hour treatment period. 1
Monitor serum potassium levels and adjust dose based on response, with the maintenance dose range being 5 g every other day to 15 g daily. 1
Up-titrate in 5 g increments at intervals of 1 week or longer if potassium remains elevated. 1
Decrease dose or discontinue if serum potassium falls below the desired target range. 1
Critical Monitoring Requirements
Check serum potassium and renal function within 1-2 weeks of initiating or adjusting lisinopril dose, and at least yearly as this patient is on an ACE inhibitor. 3, 4
In this high-risk elderly patient with diabetes risk factors and ACE inhibitor use, check potassium levels more frequently (7-10 days after starting Lokelma). 4
Monitor for edema, as each 5 g dose contains approximately 400 mg of sodium; this is particularly important given the patient's hypertension and HCTZ use. 1
Adjust dietary sodium and increase diuretic dose as needed if edema develops. 1
Important Considerations for This Patient
Do not discontinue lisinopril despite the hyperkalemia (5.4 mEq/L), as maintaining RAAS inhibition provides critical cardiovascular and renal protection. 4
The potassium level of 5.4 mEq/L is classified as mild hyperkalemia (>5.0 to <5.5 mEq/L) and does not require emergency treatment, making Lokelma appropriate. 4
In elderly hypertensive patients, potassium levels greater than 4.45 mEq/L have been associated with increased mortality, supporting the need for treatment at 5.4 mEq/L. 5
Avoid adding potassium-sparing diuretics to this regimen, as the combination of ACE inhibitor plus potassium-sparing diuretic can cause life-threatening hyperkalemia within 8-18 days. 6
Common Pitfalls to Avoid
Do not use Lokelma as emergency treatment for life-threatening hyperkalemia due to its delayed onset of action; this patient's level of 5.4 mEq/L is appropriate for Lokelma use. 1
Avoid severe constipation or bowel obstruction, as Lokelma has not been studied in these conditions and may be ineffective or worsen gastrointestinal symptoms. 1
Watch for hypokalemia development, which occurred in 10% of patients on 10 g daily maintenance in clinical trials. 2
Do not completely discontinue the ACE inhibitor rather than managing the hyperkalemia with Lokelma, as this removes cardiovascular protection. 4
Monitor for the thiazide-induced hypokalemia from HCTZ, which can complicate potassium management; in ALLHAT, chlorthalidone caused hypokalemia (<3.5 mEq/L) in 8.5% of patients. 3