How is Lokelma (sodium zirconium cyclosilicate) prescribed for a patient with hyperkalemia, macrocytic anemia, and thrombocytopenia?

How to Prescribe Lokelma (Sodium Zirconium Cyclosilicate)

Initial Treatment Phase (Correction Phase)

For acute hyperkalemia, prescribe Lokelma 10 g three times daily for up to 48 hours to rapidly lower serum potassium. 1

• Mix each 10 g dose in approximately 3 tablespoons of water, stir well, and have the patient drink immediately 1
• If powder remains in the glass, add more water, stir, and drink again until no powder remains 1
• Onset of action begins within 1 hour, with continued potassium reduction over the 48-hour period 2, 1
• Approximately 98% of patients achieve normokalaemia (3.5-5.0 mEq/L) within 48 hours 3
• Do not use Lokelma as emergency treatment for life-threatening hyperkalemia due to its delayed onset—use insulin/glucose, beta-agonists, or dialysis first 2, 1

Maintenance Treatment Phase

After achieving normokalaemia, transition to Lokelma 10 g once daily for ongoing management. 1

• The maintenance dose range is 5 g every other day to 15 g daily, adjusted based on serum potassium levels 1
• Titrate the dose in 5 g increments at intervals of 1 week or longer based on potassium monitoring 1
• Decrease the dose or discontinue if serum potassium falls below the desired target range 1
• Mean daily maintenance dose in clinical trials was approximately 7.2 g 4

Special Population: Hemodialysis Patients

For patients on chronic hemodialysis, administer Lokelma only on non-dialysis days, starting with 5 g once daily. 1

• Consider starting with 10 g once daily on non-dialysis days if serum potassium is greater than 6.5 mEq/L 1
• Adjust dose based on pre-dialysis potassium values after the long inter-dialytic interval 1
• Maintenance dose range is 5 g to 15 g once daily on non-dialysis days 1

Drug Interaction Management

Administer all other oral medications at least 2 hours before or 2 hours after Lokelma to avoid reduced absorption. 1

• Lokelma binds medications throughout the GI tract, reducing their absorption 2
• Lokelma elevates gastric pH, which affects systemic exposure of drugs with pH-dependent solubility 1
• Weak bases (like dabigatran) have decreased exposure when co-administered with Lokelma 1
• Weak acids (like furosemide and atorvastatin) have increased exposure when co-administered with Lokelma 1
• Tacrolimus exposure is decreased when co-administered with Lokelma 15 g 1

Monitoring Protocol

Check serum potassium within 1 week after initiating Lokelma or after any dose adjustment. 2, 1

• During the correction phase, monitor potassium levels after 48 hours 3
• During maintenance, assess potassium at 1 week, then individualize frequency based on clinical stability 2
• Monitor for peripheral edema due to dose-dependent sodium content (400 mg sodium per 5 g dose) 2, 1
• Watch for hypokalemia, particularly with 10 g and 15 g daily doses (incidence 10-11%) 3

Adverse Effects and Safety Considerations

The most common adverse effects are gastrointestinal symptoms (constipation, diarrhea, nausea) and dose-dependent edema. 2

• Edema incidence increases with dose: 2% with 5 g, 6% with 10 g, and 14% with 15 g daily 2, 3
• Each 10 g dose contains 1200 mg sodium during correction phase, and 400-1200 mg sodium daily during maintenance 2
• Monitor patients prone to fluid overload (heart failure, renal impairment) closely for edema 1
• Unlike sodium polystyrene sulfonate, Lokelma has not been associated with intestinal necrosis in clinical trials 5

Contraindications and Precautions

Avoid Lokelma in patients with severe constipation, bowel obstruction, or impaction, as it has not been studied in these conditions and may worsen gastrointestinal status. 1

• No absolute contraindications exist 1
• Use caution in patients who should restrict sodium intake 1
• Lokelma works throughout both small and large intestines, binding potassium and increasing fecal excretion 5

Clinical Context: Enabling RAAS Inhibitor Therapy

Lokelma allows continuation of life-saving RAAS inhibitors (ACE inhibitors, ARBs, mineralocorticoid antagonists) in patients with cardiovascular disease and CKD who develop hyperkalemia. 2, 6

• In clinical trials, 87% of patients on RAAS inhibitors at baseline continued or increased their dose while on Lokelma 4
• Among RAAS inhibitor-naïve participants, 14% were able to initiate therapy during Lokelma treatment 4
• This is critical because discontinuing RAAS inhibitors leads to worse cardiovascular and renal outcomes 6