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The Patient with Renal Dysfunction
Published in Andreas P. Kalogeropoulos, Hal A. Skopicki, Javed Butler, Heart Failure, 2023
Alexandros Briasoulis, Ily Kristine T. Yumul-Non, Paulino Alvarez
Patiromer and sodium zirconium cyclosilicate are novel potassium binders that may help mitigate hyperkalemia with angiotensin blockade and AA specifically in CKD patients. Patiromer (RLY5016) is a non-absorbed, sodium-free polymer that exchanges calcium for potassium in the gastrointestinal (GI) tract, promoting fecal potassium excretion.78 In PEARL-HF (Parallel Evaluation of RLY5016 in Heart Failure), patiromer prevented hyperkalemia in HF patients with CKD who had been on an angiotensin blockade regimen and spironolactone (25–50 mg/day).78 Sodium zirconium cyclosilicate (ZS-9) is a highly selective cation exchanger that entraps potassium in the GI tract, exchanging it for hydrogen and sodium. It can correct hyperkalemia within 48 hours and its effects are noted to be most significant in higher potassium levels at baseline.79 Prior to administration of either of these agents, careful consideration of potential adverse effects is required, such as constipation, hypomagnesemia and drug interactions (metformin, levothyroxine) with patiromer, or edema with ZS-9. Also, a low-potassium diet and loop diuretics should be attempted first before initiation of these agents.
Role of point-of-care arterial blood potassium in diagnosing pseudohyperkalemia
Published in Baylor University Medical Center Proceedings, 2022
Ghulam Mujtaba Ghumman, Abdul Baqi, Abid Nawaz Khan Adil, Vinod Khatri
An electrocardiogram showed sinus tachycardia without any ST segment, T wave, or conduction abnormalities. High-sensitivity troponins were in the normal range. The patient received calcium gluconate and regular insulin with dextrose for hyperkalemia. Repeat potassium 4 hours later was 6.7 mmol/L, and the patient received sodium zirconium cyclosilicate. Potassium levels remained in the range of 6 to 7 on repeat checks, even after multiple treatments. Arterial blood with a heparinized arterial blood gas syringe was obtained, and immediate point-of-care (POC) potassium was in the normal range, confirmed on repeat checks. The decrease in leukocyte counts also led to the normalization of potassium levels even on laboratory venous samples (Table 2). All treatments for hyperkalemia were stopped considering pseudohyperkalemia related to severe leukocytosis. The patient received treatment for coronavirus disease 2019 pneumonia and antibiotic therapy for concern of superimposed bacterial pneumonia. He was then weaned off of the ventilator. Daily arterial whole blood potassium checks remained in the normal range.
New and emerging cardiovascular and antihypertensive drugs
Published in Expert Opinion on Drug Safety, 2020
Steven G. Chrysant, George S. Chrysant
Sodium zirconium cyclosilicate (Lokelma). Sodium zirconium cyclosilicate (SZC) is an inorganic cation exchanger crystalline powder compound that thermodynamically catches potassium ions and removing them from the gastrointestinal tract [120]. Like patiromer SZC is not absorbable and has no systematic actions [121]. SZS acts within 1 hour after oral administration and it should be given initially at 10 gm three times a day for 48 hours and later in daily doses of 5 to 10 g/day for maintenance therapy. In an emergency study [122], patients with hyperkalemia (serum K+ ≥ 5.8 mEq/L) SZC given at 10 g three times/day vs placebo for 4 hours, reduced the baseline serum potassium levels of 6.4 mEq/L by 0.41 mEq/L compared to placebo of 0.27mEq/L. In the HARMONIZE-Global trial [123], SCZ given in daily doses of 5 and 10 g for 48 hours, reduced serum potassium levels in a dose-response manner, from 5.71 mEq/L to 4.38 mEq/L with 10 g/day and from 5.68 mEq/L to 4.81 mEq/L with 5 g/day, compared to placebo from 5.66 mEq/L to 5.32 mEq/L. Similar results have been reported by two other studies [124,125]. The potassium lowering action of SZC is due to its size-selective micropores in the zirconium silicate crystal structure which trap potassium ions in the gastrointestinal (GI) tract in exchange for protons and sodium.
The tolerability and safety profile of patiromer: a novel polymer-based potassium binder for the treatment of hyperkalemia
Published in Expert Opinion on Drug Safety, 2018
Several compounds in development or approved for management of HK use sodium rather than calcium exchange ions, which raises the question of safety in patients with cardiovascular or renal disease given the potential sodium load. Sodium polystyrene sulfonate (SPS), an older agent used to manage HK, exchanges potassium for sodium and can increase the risk of volume overload [7,40]. The drug label advises caution in use of SPS for patients with severe chronic HF, severe hypertension, or marked edema who cannot tolerate even a small increase in sodium load [43]. Sodium zirconium cyclosilicate (SZC), recently approved in the European Union for the treatment of HK in adults [44] also exchanges potassium for sodium [45], but has a lower sodium content (~800 mg sodium per 10 g dose [43]) than SPS [46]. Further study will be needed with SZC to assess the long-term effects of sodium load. Patiromer, in contrast, exchanges potassium for calcium [21] and has not been found to increase volume load or contribute to edema or worsening of hypertension [22,23,27,37]. While there have been no SAEs associated with hypercalcemia in patiromer studies up to 1 year, any potential clinical impact from absorbed calcium during patiromer use requires longer-term data from clinical trials and post-marketing experience.