Using of potassium binders when ACEIs or ARBs cause hyperkalemia

New Rx Lokelma will pique interest in the role of potassium binders to treat CHRONIC high potassium due to ACEIs or ARBs. Think of Lokelma (sodium zirconium cyclosilicate) as most similar to sodium polystyrene sulfonate (Kayexalate, etc) for hyperkalemia. Both exchange sodium to bind potassium. Lokelma also exchanges hydrogen. But Lokelma may cause fewer GI side effects. Veltassa (patiromer) also treats hyperkalemia. It works by exchanging calcium to bind potassium instead of sodium. 

There's interest in using these medications to help patients with high potassium stay on an angiotensin converting enzyme (ACE) inhibitors or angiotensin receptor blockers (ARBs) especially for chronic kidney disease, recent heart attack, or heart failure with reduced ejection fraction (HFrEF). But Lokelma or sodium polystyrene sulfonate can cause edema will patiromer can cause low magnesium and each should be separated from all other oral medications by a few hours to avoid interactions.

Recommend other strategies BEFORE adding a daily potassium binder. Educate patients on an ACEI or ARB to limit foods high in potassium (bananas, potatoes, beans, etc) and salt substitutes (Nu-Salt, Doctor -Salt, etc). Advise avoiding other potassium-raising medications, such as TMP/SMX or NSAIDs or backing off on doses. For example, recommend limiting spironolactone to 25 mg/day for heart failure. Suggest adding or increasing the dose of a thiazide or loop diuretic if patients also have fluid overload or hypertension. If a binder is needed, lean toward patiromer. Other binders can cause edema, which can be risky in heart failure or kidney disease. Suggest Lokelma if low magnesium prevents the use of patiromer. Lean away from sodium polystyrene sulfonate. It has less evidence of efficacy and safety in these patients despite being used for decades.

References

• Kosiborod, M., Rasmussen, H.S., Lavin, P., Qunibi, W.Y., Spinowitz, B., Packham, D., Roger, S.D., Yang, A., Lerma, E. and Singh, B. (2014). Effect of sodium zirconium cyclosilicate on potassium lowering for 28 days among outpatients with hyperkalemia: the HARMONIZE randomized clinical trial. JAMA, [online] 312(21), pp.2223–2233. Available at: https://pubmed.ncbi.nlm.nih.gov/25402495

  Georgianos, P.I. and Agarwal, R. (2018). Revisiting RAAS blockade in CKD with newer potassium-binding drugs. Kidney International, 93(2), pp.325–334. Available at: https://pubmed.ncbi.nlm.nih.gov/29276100

  Sarwar, C.M.S., Papadimitriou, L., Pitt, B., Piña, I., Zannad, F., Anker, S.D., Gheorghiade, M. and Butler, J. (2016). Hyperkalemia in Heart Failure. Journal of the American College of Cardiology, [online] 68(14), pp.1575–1589. Available at: https://www.deepdyve.com/lp/elsevier/hyperkalemia-in-heart-failure-sS9yXHEIjy