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Heart Failure Pregnancy: Avoid — insufficient safety data; seek specialist advice

Sodium Zirconium Cyclosilicate

Brand names: Lokelma

Adult dose

Dose: Acute correction: 10 g three times daily for up to 48 hours. Maintenance: 5 g once daily (range 5–15 g once daily or every other day)
Route: Oral
Frequency: Acute: three times daily; maintenance: once daily or every other day
Max: 10 g three times daily (acute phase)
Mix in 45 mL water; drink immediately; do not take on empty stomach. Acute phase: 10 g TDS for 24–48h achieves normalisation within 1–2h. Separate from other medications by 2 hours.

Paediatric dose

Dose: Seek specialist opinion N/A/kg
Route: Oral
Frequency: N/A
Max: N/A
Not established in paediatrics; seek specialist nephrology opinion

Dose adjustments

Renal

No dose adjustment — not systemically absorbed; approved for use in dialysis patients (on non-dialysis days) and CKD

Hepatic

No dose adjustment — not systemically absorbed

Paediatric weight-based calculator

Not established in paediatrics; seek specialist nephrology opinion

Clinical pearls

  • Mechanism: inorganic crystal lattice (microporous zirconium cyclosilicate) — acts as potassium ion trap in the gut throughout the GI tract (not just colon like patiromer); each crystal has high selectivity for K+ over Na+ and Ca2+; exchanges Na+/H+ for K+; faster onset than patiromer
  • DIALIZE trial (NEJM 2019): sodium zirconium cyclosilicate in dialysis patients with hyperkalaemia — 41% achieved target K+ 4.0–5.0 mmol/L pre-dialysis vs 1% placebo; first evidence-based treatment for inter-dialytic hyperkalaemia
  • KEY differences from patiromer: faster onset (1–2 hours vs 7 hours); works throughout GI tract; contains significant sodium (concern in fluid-overloaded HF/CKD); requires 2-hour separation from other drugs (vs 3 hours for patiromer)
  • MHRA 2018: licensed for hyperkalaemia in adults; NICE TA599: recommended for hyperkalaemia in adults with CKD or HF on RAASi therapy
  • Sodium content concern: 10 g dose contains approximately 400 mg sodium — significant for oedematous patients (HF, nephrotic syndrome); use lower maintenance dose or every-other-day dosing; monitor for fluid retention
  • Rapid action: can be considered for subacute hyperkalaemia correction (not immediately life-threatening) where IV treatment risks (fluid load, insulin hypoglycaemia) are problematic — e.g., haemodialysis patients, HF patients

Contraindications

  • Life-threatening or severe hyperkalaemia requiring emergency treatment — use IV treatments first
  • Bowel obstruction (relative)

Side effects

  • Oedema (sodium content of formulation — each 10 g contains approximately 400 mg sodium)
  • Hypokalaemia (with over-correction or excessive use)
  • Hypomagnesaemia (less than patiromer)
  • GI side effects: nausea, constipation

Interactions

  • All oral medications — separate by at least 2 hours (adsorption, though less promiscuous than patiromer)
  • Levothyroxine, lithium, warfarin — specific monitoring recommended (reduced absorption)

Monitoring

  • Serum potassium 1–4 hours after first dose (acute phase monitoring)
  • Serum potassium weekly during dose titration
  • Fluid balance and oedema (sodium content — especially in HF patients)
  • Other electrolytes (magnesium, calcium)

Reference: BNFc; BNF 90; DIALIZE trial NEJM 2019;380(18):1707-1716; NICE TA599; MHRA 2018; ESC HF Guidelines 2021. Verify against your local formulary and the latest BNF before prescribing.

Related

Curated clinical cross-links plus same-class fallbacks.

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