Medication Spotlight: Lokelma

Lokelma (otherwise known as sodium zirconium cyclosilicate) is a selective potassium binder which is used in the treatment of hyperkalemia in adults.

-------------------- Mechanism of Action:

Lokelma is a zirconium-based compound which selectively captures potassium, in exchange for hydrogen and sodium ions. The amount of potassium which is absorbed from the gastrointestinal tract is reduced, and the bound complex is excreted into the feces unchanged since it is not absorbed or metabolized. The onset of effect is 1 hour; hence, it is not for severe hyperkalemia emergencies. Patients achieve normal potassium levels (3.5 to 5 mmol/L) within 48 hours.

-------------------- Dosing:

-Treatment Phase: 10 grams three times daily for 48 hours, then reduce to maintenance dose -Maintenance Phase: Anywhere between 5 grams every other day, up to 10 grams daily. Highly flexible regimen to maintain normal potassium levels.

-------------------- Administration:

-The powder is mixed into 45 mL of water, stirred and administered with or without food. -Note: the powder will only be suspended in water and may settle if left in place. It appears as a cloudy liquid with no taste or colour.

-------------------- Adverse Effects:

-Hypokalemia: monitor blood potassium levels. Reduce dose or discontinue Lokelma. -Edema: each 5 gram packet contains 400 mg of sodium, so be careful of patients with fluid sensitive conditions such as kidney disease and heart failure. This is also an issue with Kayexalate. Some patients may need diuretics to manage this issue and restrict sodium intake. -Constipation: avoid in patients with severe bowel obstruction or constipation (less GI problems compared to Kayexalate due to no swelling of powder) -Muscle spasms -Increased bicarbonate levels

-------------------- Drug Interactions:

-Can be co-administered with other medications (unlike Kayexalate where 3 hour spacing is observed due to binding) -EXCEPT: atorvastatin and dabigatran - space by 2 hours before or after -Lokelma can increase gastric pH - thereby affecting acid-sensitive drugs such as antifungals (ketoconazole), protease inhibitors or tyrosine kinase inhibitors. Space apart by 2 hours.

-------------------- Role in Therapy:

Currently, the most commonly used potassium binder is Kayexalate (sodium polystyrene sulfonate). In terms of efficacy, Lokelma does work for normalizing potassium levels, but there are no head-to-head trials between Lokelma and Kayexalate. Plus, there are no hard clinical outcomes (quality of life, overall survival), since potassium is a surrogate lab value outcome.

There are some potential advantages of Lokelma, which may include better GI tolerance and less drug interactions. It is highly selective for potassium, so it is less likely to affect magnesium and calcium compared to Kayexalate.

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