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

Lokelma Dosing for Potassium 6.4 mEq/L

For a potassium level of 6.4 mEq/L (moderate hyperkalemia), 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 into the normal range (3.5-5.0 mEq/L). 1 This dosing regimen achieves:

• Mean serum potassium reduction from 5.6 to 4.5 mEq/L within 48 hours 2
• Median time to normalization of 2.2 hours, with 84% of patients achieving normokalemia by 24 hours 2
• Mean reduction of 0.7 mEq/L with the 10 g three times daily regimen 3

Mix each 10 g dose in approximately 3 tablespoons of water, stir well, and drink immediately. 1 If powder remains, add more water and repeat until the entire dose is consumed. 1

Maintenance Phase (After 48 Hours)

Transition to Lokelma 10 g once daily after the initial 48-hour correction phase. 1 This maintenance dose:

• Maintains mean serum potassium at 4.5 mEq/L during days 8-29 2
• Achieves normokalemia in 90% of patients receiving 10 g daily 2
• Sustains potassium control for up to 12 months with mean serum potassium of 4.7 mEq/L 4

Adjust the maintenance dose in 5 g increments at intervals of 1 week or longer based on serum potassium levels. 1 The maintenance dose range is 5 g every other day to 15 g daily. 1

Critical Monitoring Protocol

Check serum potassium after 48 hours to assess response to initial therapy, then weekly during dose titration. 5 Once stable on maintenance therapy, monitor potassium at 3 days, 1 week, and monthly for the first 3 months. 6

Decrease or discontinue Lokelma if serum potassium falls below the desired target range. 1 Hypokalemia occurred in 10% of patients receiving 10 g daily in clinical trials. 2

Medication Timing Considerations

Administer other oral medications at least 2 hours before or 2 hours after Lokelma to avoid reduced absorption due to binding in the gastrointestinal tract. 1 This separation is particularly important for medications with narrow therapeutic windows. 7

Special Considerations for Your Patient

At potassium 6.4 mEq/L, this represents moderate hyperkalemia requiring prompt but not emergent treatment. 5 Lokelma is appropriate for this scenario because:

• Lokelma should NOT be used for life-threatening hyperkalemia (typically >6.5 mEq/L with ECG changes) due to its delayed onset of action. 1
• Your patient's potassium of 6.4 mEq/L falls into the moderate range where Lokelma's 1-hour onset is acceptable. 7, 5
• If ECG changes are present (peaked T waves, widened QRS, prolonged PR interval), administer IV calcium gluconate first for cardiac membrane stabilization while initiating Lokelma. 5

Do not discontinue RAAS inhibitors (ACE inhibitors, ARBs, mineralocorticoid antagonists) if the patient is on them for cardiovascular or renal protection. 7, 5 Instead, use Lokelma to enable continuation of these life-saving medications. 7, 6

Monitoring for Adverse Effects

Monitor for edema, particularly if using the 15 g daily dose. 1, 2 Each 5 g dose contains approximately 400 mg of sodium, though the extent of absorption is unknown. 1 Edema occurred in 14% of patients receiving 15 g daily versus 2% with placebo. 2

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

Expected Timeline

• 1 hour: Initial potassium-lowering effect begins 7, 5
• 24 hours: 84% of patients achieve normokalemia 2
• 48 hours: 98% of patients achieve normokalemia 2
• Days 8-29: Maintenance of potassium at 4.5 mEq/L with 10 g daily 2

Reassess potassium 7-10 days after initiating Lokelma to guide dose adjustments. 5 The goal is to maintain potassium in the range of 4.0-5.0 mEq/L to minimize mortality risk. 5, 6