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LOKELMA® (sodium zirconium cyclosilicate) is indicated for the treatment of hyperkalaemia in adult patients.
Effective management of hyperkalaemia is crucial to maintaining optimal patient outcomes while continuing the use of Renin-Angiotensin-Aldosterone System inhibitors (RAASi). Hyperkalaemia should no longer be a barrier to optimising RAASi therapy.1
Current hyperkalaemia clinical guidelines support the use of potassium (K+) binders to manage hyperkalaemia, allowing the continuation of RAASi therapy, with dose reduction being considered only as a last resort.1-7
Persistent hyperkalaemia requires ongoing management to ensure effective and sustained control.6
The primary treatment goal for persistent hyperkalaemia is to prevent its development or recurrence by correcting the underlying disturbance in K+ homeostasis.7
ESC 2021 guidelines support the use of an approved K+ lowering agent in patients with chronic or recurrent hyperkalaemia on RAASi therapy as soon as K+ levels exceed 5.0 mmol/L.6
ESC guidelines state that the administration of K+-lowering agents, such as sodium zirconium cyclosilicate or patiromer, may allow the initiation or up-titration of RAASi in a larger proportion of patients.8
For the management of hyperkalaemia associated with angiotensin-converting enzyme inhibitor (ACEi) or angiotensin receptor blockers (ARB), the Kidney Disease: Improving Global Outcomes (KDIGO) guidelines, relating to the management of blood pressure and to the management of diabetes in patients with CKD, support the use of K+ binders over decreasing or discontinuing ACEi/ARB therapy.3,4
KDIGO 2024 guideline for CKD affirms that for patients with hyperkalaemia:5
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Figure reproduced with permission from KDIGO 2024 CKD Clinical Practice Guideline.
Figure reproduced with permission from KDIGO 2024 CKD Clinical Practice Guideline.
Management of chronic hyperkalaemia should be guided by severity and with the aims of preventing recurrence and supporting RAASi optimisation where possible, which is key to patients achieving the Four Pillars of Heart Failure.1
Adapted from Alfonzo et al (2023)1, the Veltassa SmPC15 and Lokelma SmPC14
**Typically, normokalaemia is achieved within 24 to 48 hours. If patients are still hyperkalaemic after 48 hours of treatment, the same regimen can be continued for an additional 24 hours. If normokalaemia is not achieved after 72 hours of treatment, other treatment approaches should be considered.
Based on a Delphi consensus regarding best practices for hyperkalaemia management, K+ binders are recommended as the preferred agents to manage hyperkalaemia and should be used to enable and maintain optimised RAASi therapy. Additionally, RAASi use should not be reduced or discontinued solely due to hyperkalaemia, unless alternative measures of hyperkalaemia management have been optimised.2
Treatment and management recommendations vary among hyperkalaemia clinical guidelines, and, as such, the treatment of hyperkalaemia is currently variable.1 However, there is a shared objective to manage hyperkalaemia effectively to enable patients with heart failure (HF) and CKD to maintain optimal RAASi therapy.3-10
Collaboration with specialist services such as renal and HF teams can facilitate strategies to avoid RAASi discontinuation and support the tolerable reintroduction of RAASi treatment for patients.1
Patients with severe hyperkalaemia, or who have mild-to-moderate hyperkalaemia and have acute kidney injury (AKI) or are acutely ill, should be referred to hospital for emergency treatment.1
The hyperkalaemia treatment algorithm for hospitalised patients outlines a sequential approach of 5 steps:1
Clear communication between primary and secondary care is key for continuity of care after hospital discharge for hyperkalaemia.1
Learn more about acute and persistent hyperkalaemia.1
Adapted from Alfonzo et al (2020)1, the Veltassa SmPC15 and Lokelma SmPC14
*Insulin, glucose and salbutamol are not licensed in the UK for the treatment of hyperkalaemia. Refer to their summaries of product characteristics,
**Typically, normokalaemia is achieved within 24 to 48 hours. If patients are still hyperkalaemic after 48 hours of treatment, the same regimen can be continued for an additional 24 hours. If normokalaemia is not achieved after 72 hours of treatment, other treatment approaches should be considered.
The treatment goal for acute hyperkalaemia is to induce K+ flux into the intracellular space and remove K+ from the body to prevent cardiac arrhythmias.7
Treatment | Mechanism of action | Characteristics and limitations / side effects | Limitations / Side Effects |
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| Calcium gluconate / calcium chloride | Membrane stabilisation of myocardium |
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| Insulin and glucose* | K+ redistribution into the intracellular space |
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| B2-adrenergic agonists* | K+ redistribution into the intracellular space |
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| Dialysis (haemodialysis, peritoneal dialysis) | K+ elimination |
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| Diuretics (loop and thiazide) | Promote renal K+ excretion |
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| Low Potassium Diet | Reduction of K+ intake |
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| Downtritation / discontinuation of RAASi | Prevention of hyperkalaemia as RAASi treatment adverse event |
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* Insulin, glucose and B2 agonists are not licensed in the UK for the treatment of acute hyperkalaemia. Refer to their summaries of product characteristics.
According to NICE guidance, sodium zirconium cyclosilicate is recommended for treating hyperkalaemia in adults under specific conditions. It can be used in emergency care for acute life-threatening hyperkalaemia alongside standard care. Additionally, it is recommended for people with persistent hyperkalaemia and CKD stage 3b to 5 or heart failure if they meet the following criteria:11
Sodium zirconium cyclosilicate should be discontinued if RAAS inhibitors are no longer appropriate for the patient.11
The Scottish Medicines Consortium (SMC) accepts (restricted use) sodium zirconium cyclosilicate in both the emergency care setting and in outpatients for adult patients with hyperkalaemia in Scotland.12,13
Adults admitted to an emergency care setting in Scotland with acute, life-threatening hyperkalaemia will be able to access sodium zirconium cyclosilicate as a treatment option to be used alongside standard care.
Sodium zirconium cyclosilicate was the first pharmacological therapy accepted by the SMC to treat adults in both:12,13
ABCDE, airway breathing circulation disability exposure; ACEi, angiotensin-converting enzyme inhibitor; AKI, acute kidney injury; ARB, angiotensin receptor blockers; CKD, chronic kidney disease; DASH, dietary approaches to stop hypertension; ECG, electrocardiogram; ESC, European Society of Cardiology; HF, heart failure; IV, intravenous; KDIGO, Kidney Disease: Improving Global Outcomes; NICE, National Institute for Health and Care Excellence; NSAIDs, non-steroidal anti-inflammatory drugs; MRA, mineralocorticoid receptor antagonist; RAASi, renin-angiotensin-aldosterone system inhibitors; SMC, Scottish Medicines Consortium; SZC, sodium zirconium cyclosilicate; UKKA, UK Kidney Association.
GB-63502 | DOP: February 2025
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