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Content Update

May 24, 2018

Sodium Zirconium Cyclosilicate (Lokelma) for Treatment of Hyperkalemia: In May 2018, the U.S. Food and Drug Administration approved sodium zirconium cyclosilicate for treatment of hyperkalemia in adults. The drug is a cation exchange resin that exchanges potassium for sodium and hydrogen in the gut lumen, thereby increasing fecal potassium excretion; this reduces free potassium concentrations and lowers serum potassium levels. It represents the third cation exchange resin available for commercial use in addition to sodium polystyrene sulfonate (Kayexalate) and patiromer sorbitex calcium (Veltassa). Healthcare providers should be knowledgeable about each drug's efficacy, dosing, adverse effects, precautions, drug interactions, and cost prior to clinical use.


Patient Care Process for the Management of Potassium and Magnesium Disorders



  • Patient characteristics (e.g., age, race, sex)

  • Patient history (past medical, family, social—dietary habits)

  • Current medications, including over-the-counter medications, herbal products, nutritional supplements, current diet

  • Presence of symptoms (musculoskeletal and neuromuscular review of systems; see Clinical Presentation boxes)

  • Objective data

    • Blood pressure, heart rate, height, weight

    • Labs (e.g., basic metabolic panel, calcium, magnesium, phosphorus)

    • Fluid balance (intake and output)

    • Other diagnostic tests when indicated (e.g., ECG, urinalysis, urine electrolytes; see Figure 51-1)


  • Severity of electrolyte disorder (e.g., change from baseline value, timing of development of electrolyte disorder)

  • Kidney function (e.g., eGFR, calculated creatinine clearance)

  • Current medications that may contribute to electrolyte disorder (see Tables 51-1, 51-6, and 51-8)

  • Current diet that may contribute to electrolyte disorder (see Tables 51-2 and 51-9)

  • Most likely cause of the electrolyte disorder


  • Dietary modifications (see Tables 51-2 and 51-9)

  • Discontinue any offending medications or substances (if possible)

  • Pharmacotherapy including specific medication, dose, route, frequency, and duration; specify the continuation and discontinuation of existing therapies (see Tables 51-4, 51-1, and 51-7)

  • Monitoring parameters including efficacy (e.g., potassium, magnesium, SCr), safety (medication-specific adverse effects)

  • Patient education (e.g., purpose of treatment, dietary and lifestyle modification, drug therapy)

  • Referrals to other providers when appropriate (e.g., physician, dietician)


  • Provide patient education regarding all elements of treatment plan

  • Use motivational interviewing and coaching strategies to maximize adherence

  • Schedule follow-up (within 24 hours if inpatient and 1-2 weeks if outpatient, depending on severity and acuity of disorder)

Follow-up: Monitor and Evaluate

  • Resolution of electrolyte disorder

  • Presence of adverse effects

  • Development/progression of kidney impairment

  • Adherence to treatment plan using multiple sources of information (e.g., patient interview, medication administration record)

*Collaborate with patient, caregivers, and other health professionals



  • image Potassium regulates many biochemical processes in the body and is a key cation for electrical action potentials across cellular membranes.

  • image In patients with concomitant hypokalemia and hypomagnesemia, it is imperative to correct the hypomagnesemia before the hypokalemia.

  • image Potassium chloride is the preferred potassium supplement for the most common causes of hypokalemia.

  • image Hyperkalemia is a common occurrence in patients with acute kidney injury or ...

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