What is the initial dose of Lokelma (sodium zirconium cyclosilicate) for a patient with mild hyperkalemia (potassium level of 5.5)?

Lokelma Dosing for Potassium 5.5 mEq/L

For a potassium level of 5.5 mEq/L, initiate Lokelma (sodium zirconium cyclosilicate) at 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 levels in patients with mild to moderate hyperkalemia 1
• This dosing regimen achieves normalization of potassium (3.5-5.0 mEq/L) within 2.2 hours (median time) in most patients, with 84% achieving normalization by 24 hours and 98% by 48 hours 2
• The exponential rate of change in mean serum potassium at 48 hours with SZC 10 g three times daily is 0.30% per hour, significantly superior to placebo (P<.001) 3
• Mean serum potassium reduction is approximately 1.1 mEq/L over the first 48 hours with this dosing regimen 3

Maintenance Phase (After 48 Hours)

• Transition to Lokelma 10 g once daily after achieving normalization during the initial 48-hour treatment period 1
• Monitor serum potassium levels and adjust the maintenance dose based on response, with the recommended range being 5 g every other day to 15 g daily 1
• During maintenance therapy, mean serum potassium levels of 4.8 mEq/L, 4.5 mEq/L, and 4.4 mEq/L are achieved with 5 g, 10 g, and 15 g once daily dosing respectively, all significantly lower than placebo (5.1 mEq/L; P<.001 for all comparisons) 2
• Up-titrate the dose in 5 g increments at intervals of 1 week or longer based on serum potassium levels and desired target range 1

Administration Instructions

• Administer other oral medications at least 2 hours before or 2 hours after Lokelma to avoid potential drug interactions, as SZC can bind other medications in the gastrointestinal tract 1
• Empty the entire contents of the packet into approximately 3 tablespoons of water, stir well, and drink immediately 1
• If powder remains in the glass, add more water, stir, and drink again until no powder remains to ensure the entire dose is taken 1

Monitoring and Dose Adjustments

• Check serum potassium within 24-48 hours after initiating therapy to assess response 4
• During maintenance treatment, monitor potassium levels at 1 week after dose adjustments, then at 3 months, and subsequently every 6 months 4
• Decrease the dose or discontinue Lokelma if serum potassium falls below the desired target range (typically 4.0-5.0 mEq/L) 1, 4
• For patients with potassium levels between 5.1-5.5 mEq/L, the 10 g three times daily regimen is appropriate, while higher levels (>5.5 mEq/L) may require the same initial dosing but closer monitoring 3, 4

Special Considerations

• Each 5 g dose of Lokelma contains approximately 400 mg of sodium, so monitor for signs of edema, particularly in patients who should restrict sodium intake or are prone to fluid overload 1
• Edema was observed in clinical trials and was generally mild to moderate, occurring more commonly in patients treated with 15 g once daily (14% incidence) 2
• Avoid use in patients with severe constipation, bowel obstruction, or impaction, as Lokelma has not been studied in these conditions and may worsen gastrointestinal symptoms 1
• Do not use Lokelma as emergency treatment for life-threatening hyperkalemia due to its delayed onset of action; it is designed for subacute management 1

Efficacy Across Patient Populations

• The beneficial effects of SZC are consistent across all patient subgroups, including those with chronic kidney disease, diabetes, heart failure, and those on concurrent RAAS inhibitor therapy 5
• In patients with CKD stages 4-5,82% achieved normokalaemia within 24 hours during the correction phase, and 82% maintained normokalaemia at Day 365 during maintenance therapy 6
• The incidence of hypokalemia with SZC is low, occurring in approximately 10-11% of patients receiving 10-15 g once daily maintenance doses, with no cases reported in the 5 g group 2

Common Pitfalls to Avoid

• Do not permanently discontinue beneficial RAAS inhibitors due to mild hyperkalemia at 5.5 mEq/L; instead, initiate Lokelma to maintain cardioprotective and renoprotective medications 4, 7
• Avoid administering Lokelma simultaneously with other oral medications, as it can reduce their absorption through binding in the gastrointestinal tract 1
• Do not use the same dosing regimen for patients on chronic hemodialysis; these patients require a different starting dose (5 g once daily on non-dialysis days) 1
• Monitor for recurrence of hyperkalemia if Lokelma is discontinued, particularly in patients on higher doses of RAAS inhibitors (equivalent enalapril dose >2.5 mg/day), as they have significantly higher risk of rapid recurrence 8