Starting Dose for Lokelma in Adult Hyperkalemia
Start with Lokelma 10 g three times daily for up to 48 hours, then transition to 10 g once daily for maintenance. This is the FDA-approved initial dosing regimen and is supported by the strongest clinical trial evidence for rapid potassium reduction and sustained control. 1
Initial Treatment Phase (First 48 Hours)
The standard starting dose is 10 g administered three times daily for up to 48 hours. 1 This regimen achieves:
- Mean serum potassium reduction of 1.1 mEq/L (from 5.6 mEq/L to 4.5 mEq/L) 2
- Onset of action within 1 hour of the first dose 2
- 84% of patients achieve normokalemia within 24 hours, and 98% within 48 hours 3
The 10 g three-times-daily dose demonstrates a 0.30% exponential rate of change in serum potassium at 48 hours, which is the most effective studied dose. 2 All doses ≥2.5 g showed statistical significance versus placebo (P<0.001), but the 10 g dose provides superior efficacy. 2
Do not use a 5 g starting dose. The 5 g dose is reserved for maintenance therapy or for patients on chronic hemodialysis. 1 Starting with 5 g would provide only a 0.21% rate of change versus the 0.30% achieved with 10 g, resulting in slower and less complete potassium reduction. 2
Transition to Maintenance Therapy
After achieving normokalemia within 48 hours, transition to 10 g once daily. 1 This maintenance dose:
- Maintains 90% of patients in normokalemia over 28 days 2
- Keeps mean serum potassium at 4.5 mEq/L during maintenance 3
- Provides sustained efficacy for up to 11-12 months, with 88% of patients maintaining mean serum potassium ≤5.1 mEq/L 2
The FDA label explicitly states: "For continued treatment, the recommended dose is 10 g once daily." 1 You can adjust between 5 g every other day and 15 g daily based on serum potassium levels, but 10 g once daily is the standard starting maintenance dose. 1
Monitoring Protocol
Check serum potassium within 2-4 weeks after initiation or dose adjustment. 2 The FDA label recommends monitoring serum potassium and adjusting the dose based on levels and desired target range. 1
- During initiation: Monitor within the first 5-7 days after starting Lokelma 4
- Once stable: Check at 3 months, then every 6 months 4
- If potassium falls below target: Decrease the dose or discontinue 2, 1
Special Populations
Patients on Chronic Hemodialysis
Start with 5 g once daily on non-dialysis days (not 10 g). 1 Consider 10 g once daily on non-dialysis days only if serum potassium is >6.5 mEq/L. 1 Administer Lokelma only on non-dialysis days. 1
Patients with Severe Hyperkalemia (≥6.0 mEq/L)
Still use 10 g three times daily for 48 hours. 1 However, recognize that Lokelma should not be used as emergency treatment for life-threatening hyperkalemia due to its delayed onset of action (1 hour). 1 For severe hyperkalemia with ECG changes, use immediate interventions (calcium, insulin/glucose, albuterol) first, then add Lokelma. 2
Safety Considerations
Each 5 g dose contains approximately 400 mg of sodium. 1 Monitor for edema, particularly in patients who should restrict sodium intake or are prone to fluid overload (heart failure, renal disease). 1 In clinical trials:
- Edema occurred in 6% of patients on 10 g daily versus 14% on 15 g daily 2
- Hypokalemia was infrequent and occurred in 10% of patients on 10 g maintenance 3
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
Drug Interactions
Administer other oral medications at least 2 hours before or 2 hours after Lokelma. 1 This separation prevents Lokelma from binding other medications in the gastrointestinal tract and reducing their absorption. 1
Why Not Start with 5 g?
The 5 g dose is not recommended for initial treatment because:
- Slower potassium reduction: 5 g produces only a 0.21% rate of change versus 0.30% with 10 g 2
- Lower efficacy: Only 80% of patients on 5 g maintenance maintained normokalemia versus 90% on 10 g 3
- FDA labeling: The approved initial dose is 10 g three times daily, not 5 g 1
The 5 g dose is appropriate for:
- Maintenance therapy in patients who achieve normokalemia on 10 g and need dose reduction 1
- Hemodialysis patients as the starting dose on non-dialysis days 1
- Patients who develop hypokalemia on 10 g maintenance 1
Clinical Context
Do not discontinue RAAS inhibitors (ACE inhibitors, ARBs, aldosterone antagonists) when starting Lokelma. 2 The newer potassium binders like Lokelma enable optimization of cardioprotective RAAS inhibitor therapy while managing hyperkalemia. 2 This is a critical advantage over older binders like sodium polystyrene sulfonate (SPS), which has been associated with serious gastrointestinal adverse events. 2
Lokelma works in both the small and large intestines, contributing to its faster onset of action (1 hour) compared to patiromer (7 hours). 2 It is more selective for potassium than SPS and has a more favorable side effect profile. 2