Sodium zirconium cyclosilicate

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# Overview
Sodium zirconium cyclosilicate is a potassium binder that is FDA approved for the treatment of hyperkalemia in adults.   Common adverse reactions include mild to moderate edema.

# Adult Indications and Dosage

## FDA-Labeled Indications and Dosage (Adult)
- Sodium zirconium cyclosilicate is indicated for the treatment of hyperkalemia in adults.
- Sodium zirconium cyclosilicate should not be used as an emergency treatment for life-threatening hyperkalemia because of its delayed onset of action.
- For initial treatment of hyperkalemia, the recommended dose of sodium zirconium cyclosilicate is 10 g administered three times a day for up to 48 hours. Administer sodium zirconium cyclosilicate orally as a suspension in water.
- For continued treatment, the recommended dose is 10 g once daily. Monitor serum potassium and adjust the dose of sodium zirconium cyclosilicate based on the serum potassium level and desired target range. During maintenance treatment, the dose may be up-titrated based on the serum potassium level at intervals of 1-week or longer and in increments of 5 g. The dose of sodium zirconium cyclosilicate should be decreased or discontinued if the serum potassium is below the desired target range. The recommended maintenance dose range is from 5 g every other day to 15 g daily.
- For oral suspension: 5 g or 10 g of white powder in a foil-lined packet.

## Off-Label Use and Dosage (Adult)

### Guideline-Supported Use
There is limited information regarding sodium zirconium cyclosilicate Off-Label Guideline-Supported Use and Dosage (Adult) in the drug label.

### NonGuideline-Supported Use
There is limited information regarding sodium zirconium cyclosilicate Off-Label Non-Guideline-Supported Use and Dosage (Adult) in the drug label.

# Pediatric Indications and Dosage

## FDA-Labeled Indications and Dosage (Pediatric)
There is limited information regarding Sodium zirconium cyclosilicate FDA-Labeled Indications and Dosage (Pediatric) in the drug label.

## Off-Label Use and Dosage (Pediatric)

### Guideline-Supported Use
There is limited information regarding sodium zirconium cyclosilicate Off-Label Guideline-Supported Use and Dosage (Pediatric) in the drug label.

### NonGuideline-Supported Use
There is limited information regarding sodium zirconium cyclosilicate Off-Label Non-Guideline-Supported Use and Dosage (Pediatric) in the drug label.

# Contraindications
- None.

# Warnings
- Avoid use of sodium zirconium cyclosilicate in patients with severe constipation, bowel obstruction or impaction, including abnormal postoperative bowel motility disorders, because sodium zirconium cyclosilicate has not been studied in patients with these conditions and may be ineffective and may worsen gastrointestinal conditions.
- Each 5 g dose of sodium zirconium cyclosilicate contains approximately 400 mg of sodium. In clinical trials of sodium zirconium cyclosilicate, edema was generally mild to moderate in severity and was more commonly seen in patients treated with 15 g once daily. Monitor for signs of edema, particularly in patients who should restrict their sodium intake or are prone to fluid overload (e.g., heart failure or renal disease). Advise patients to adjust dietary sodium, if appropriate. Increase the dose of diuretics as needed.

# Adverse Reactions

## Clinical Trials Experience
- Because clinical studies are conducted under widely varying conditions, adverse reaction rates observed in the clinical studies of a drug cannot be directly compared to rates in the clinical studies of another drug and may not reflect the rates observed in practice.
- The total exposure to sodium zirconium cyclosilicate in the safety and efficacy clinical trials of patients with hyperkalemia was 1,760 patients with 652 patients exposed to sodium zirconium cyclosilicate for at least 6 months and 507 patients exposed for at least one year.
- The population (n=1,009) in the placebo-controlled trials included patients aged 22 to 96 years, females (n=454), Caucasians (n=859) and Blacks (n=130). Patients had hyperkalemia in association with comorbid diseases such as chronic kidney disease, heart failure and diabetes mellitus.
- In placebo-controlled trials in which patients were treated with once daily doses of sodium zirconium cyclosilicate for up to 28 days, edema was reported in 4.4% of patients receiving 5 g, 5.9% of patients receiving 10 g and 16.1% of patients receiving 15 g sodium zirconium cyclosilicate compared to 2.4% of patients receiving placebo. In longer-term uncontrolled trials in which most patients were maintained on doses <15 g once daily, adverse reactions of edema (edema, generalized edema and peripheral edema) were reported in 8% to 11% of patients.
- In clinical trials, 4.1% of sodium zirconium cyclosilicate-treated patients developed hypokalemia with a serum potassium value less than 3.5 mEq/L, which resolved with dosage reduction or discontinuation of sodium zirconium cyclosilicate.

## Postmarketing Experience
There is limited information regarding Sodium zirconium cyclosilicate Postmarketing Experience in the drug label.

# Drug Interactions
- sodium zirconium cyclosilicate can transiently increase gastric pH. As a result, sodium zirconium cyclosilicate can change the absorption of co-administered drugs that exhibit pH-dependent solubility, potentially leading to altered efficacy or safety of these drugs when taken close to the time sodium zirconium cyclosilicate is administered. In general, other oral medications should be administered at least 2 hours before or 2 hours after sodium zirconium cyclosilicate. Sodium zirconium cyclosilicate is not expected to impact systemic exposure of drugs that do not exhibit pH-dependent solubility and so spacing is not needed if it has been determined that the concomitant medication does not exhibit pH-dependent solubility.

# Use in Specific Populations

### Pregnancy
Pregnancy Category (FDA):
- Sodium zirconium cyclosilicate is not absorbed systemically following oral administration and maternal use is not expected to result in fetal exposure to the drug.
Pregnancy Category (AUS): 
There is no Australian Drug Evaluation Committee (ADEC) guidance on usage of Sodium zirconium cyclosilicate in women who are pregnant.

### Labor and Delivery
There is no FDA guidance on use of Sodium zirconium cyclosilicate during labor and delivery.

### Nursing Mothers
- Sodium zirconium cyclosilicate is not absorbed systemically following oral administration, and breastfeeding is not expected to result in exposure of the child to sodium zirconium cyclosilicate.

### Pediatric Use
- Safety and effectiveness in pediatric patients have not been established.

### Geriatic Use
- Of the total number of subjects in clinical studies of sodium zirconium cyclosilicate, 58% were age 65 and over, while 25% were 75 and over. No overall differences in safety or effectiveness were observed between these patients and younger patients.

### Gender
There is no FDA guidance on the use of Sodium zirconium cyclosilicate with respect to specific gender populations.

### Race
There is no FDA guidance on the use of Sodium zirconium cyclosilicate with respect to specific racial populations.

### Renal Impairment
There is no FDA guidance on the use of Sodium zirconium cyclosilicate in patients with renal impairment.

### Hepatic Impairment
There is no FDA guidance on the use of Sodium zirconium cyclosilicate in patients with hepatic impairment.

### Females of Reproductive Potential and Males
There is no FDA guidance on the use of Sodium zirconium cyclosilicate in women of reproductive potentials and males.

### Immunocompromised Patients
There is no FDA guidance one the use of Sodium zirconium cyclosilicate in patients who are immunocompromised.

# Administration and Monitoring

### Administration
- In general, other oral medications should be administered at least 2 hours before or 2 hours after sodium zirconium cyclosilicate.
- Instruct patients to empty the entire contents of the packet(s) into a drinking glass containing approximately 3 tablespoons of water or more if desired. Stir well and drink immediately. If powder remains in the drinking glass, add water, stir and drink immediately. Repeat until no powder remains to ensure the entire dose is taken.

### Monitoring
- Improvement in serum potassium levels is indicative of efficacy.
- Serum potassium levels: Regularly.
- Signs of edema: Particularly in patients with restricted sodium intake and those prone to fluid overload (ie, heart failure, renal disease).

# IV Compatibility
There is limited information regarding the compatibility of Sodium zirconium cyclosilicate and IV administrations.

# Overdosage
There is limited information regarding Sodium zirconium cyclosilicate overdosage.  If you suspect drug poisoning or overdose, please contact the National Poison Help hotline (1-800-222-1222) immediately.

# Pharmacology

## Mechanism of Action
- Sodium zirconium cyclosilicate (sodium zirconium cyclosilicate) is a non-absorbed zirconium silicate that preferentially captures potassium in exchange for hydrogen and sodium. In vitro, sodium zirconium cyclosilicate has a high affinity for potassium ions, even in the presence of other cations such as calcium and magnesium. Sodium zirconium cyclosilicate increases fecal potassium excretion through binding of potassium in the lumen of the gastrointestinal tract. Binding of potassium reduces the concentration of free potassium in the gastrointestinal lumen, thereby lowering serum potassium levels.

## Structure
(Description with picture)

## Pharmacodynamics
- In a study in healthy adult subjects, sodium zirconium cyclosilicate administered as 5 g or 10 g once daily for four days caused a dosedependent increase in fecal potassium excretion. Corresponding dose-dependent decreases in urinary potassium excretion and serum potassium were also observed.
- In patients with hyperkalemia treated with sodium zirconium cyclosilicate 10 g three times a day for up to 48 hours, reductions in serum potassium were observed one hour after initiation of therapy; serum potassium concentrations continued to decline over the 48-hour treatment period. In patients not continuing sodium zirconium cyclosilicate, potassium levels increased. Patients with higher starting serum potassium levels or receiving a higher dose have greater reductions in serum potassium.
- Sodium zirconium cyclosilicate causes a small dose-dependent increase in serum bicarbonate concentrations (1.1 mmol/L at 5 g once daily, 2.3 mmol/L at 10 g once daily and 2.6 mmol/L at 15 g once daily as compared with a mean increase of 0.6 mmol/L in patients treated with placebo). The clinical significance of this finding is unclear.

## Pharmacokinetics
- Sodium zirconium cyclosilicate is an inorganic, insoluble compound that is not subject to enzymatic metabolism. In a clinical study in patients with hyperkalemia in which zirconium concentrations were measured in the urine and blood, zirconium concentrations were similar in treated and untreated patients (i.e., either undetectable or around the lower limit of quantification of the assay). An in vivo mass balance study in rats showed that sodium zirconium cyclosilicate was recovered in the feces with no evidence of systemic absorption.
- Thirty-nine (39) drugs were tested to determine potential interactions with sodium zirconium cyclosilicate.
- Sixteen (16) drugs tested did not show an in vitro interaction with sodium zirconium cyclosilicate (allopurinol, apixaban, aspirin, captopril, cyclosporine, digoxin, ethyl estradiol, lisinopril, magnesium, metformin, phenytoin, prednisone, propranolol, quinapril, spironolactone and ticagrelor).
- Nine (9) of the 23 drugs that showed an in vitro interaction were subsequently tested in vivo in healthy volunteers. Losartan, glipizide and levothyroxine did not show any changes in exposure when co-administered with sodium zirconium cyclosilicate. However, there was an increase in systemic exposure to weak acids such as furosemide and atorvastatin, and a decrease in systemic exposure to weak bases such as dabigatran when co-administered with sodium zirconium cyclosilicate, as shown in Figure 2. These changes are consistent with the hypothesis that sodium zirconium cyclosilicate, by elevating gastric pH, affects the systemic exposure of coadministered drugs whose solubility is pH-dependent.

## Nonclinical Toxicology
- The following tests for mutagenic potential of sodium zirconium cyclosilicate were negative: (1) the Ames (S. typhimurium and E. coli) test; (2) chromosomal aberration assay in Chinese Hamster Ovary (CHO) cells; and (3) in vivo rat micronucleus assay. Given that zirconium cyclosilicate is not genotoxic, not absorbed from the gastrointestinal tract, and did not cause local gastrointestinal alterations in a chronic toxicity study in dogs, carcinogenicity studies in animals to evaluate tumorigenic potential of sodium zirconium cyclosilicate were not deemed to be necessary.
- Fertility in male and female rats has been assessed at doses up to a Human Equivalent Dose (HED) of 58 g per day (the maximum feasible dose) with no adverse effects.

# Clinical Studies
- The effectiveness of sodium zirconium cyclosilicate in lowering serum potassium was demonstrated in a two-part, double-blind, randomized, placebo-controlled clinical trial (NCT01737697) in patients with hyperkalemia (5 to 6.5 mEq/L, mean potassium 5.3 mEq/L), Study 1.
- In the first phase of the trial (the acute phase), 753 patients were randomized to receive one of four doses of sodium zirconium cyclosilicate (1.25, 2.5, 5, or 10 g) or placebo, administered three times daily for the initial 48 hours with meals.
- The mean age of patients was 66 years, 59% of patients were men, and 86% were Caucasian. Approximately 60% of patients had chronic kidney disease, 10% had heart failure, 62% had diabetes mellitus, and 67% were on renin angiotensin aldosterone system (RAAS) inhibitor therapy at baseline.
- The primary endpoint in the acute phase was the difference in the exponential rate of change in serum potassium levels during the initial 48 hours of study drug treatment, comparing placebo-treated patients and sodium zirconium cyclosilicate-treated patients. The study met its primary endpoint demonstrating a greater reduction in serum potassium levels for the 2.5, 5, and 10 g (three times a day) dose groups compared to the placebo group (p < 0.001). As displayed in Table 1 for the secondary endpoint of potassium change from baseline, sodium zirconium cyclosilicate showed dose-dependent reductions in serum potassium at 2.5, 5, and 10 g. In patients administered 10 g TID, the mean serum potassium reduction was -0.7 mEq/L at 48 hours. Patients with higher starting potassium levels had a greater response to sodium zirconium cyclosilicate. Sodium zirconium cyclosilicate was effective in lowering potassium levels in patients with chronic kidney disease, heart failure, diabetes mellitus and those taking RAAS inhibitor therapy.
- Patients who achieved a potassium level between 3.5 and 5 mEq/L after receiving sodium zirconium cyclosilicate during the acute phase were re-randomized to receive once daily placebo or 1.25, 2.5, 5, or 10 g of once daily sodium zirconium cyclosilicate for 12 days together with breakfast.
- The primary endpoint in the maintenance phase was the difference in the exponential rate of change in serum potassium levels over the 12-day treatment interval, comparing patients receiving sodium zirconium cyclosilicate and patients receiving placebo. The study met the primary efficacy endpoint at the 5 and 10 g doses when compared with their respective placebo groups (p<0.01 and p<0.001).
- The efficacy of sodium zirconium cyclosilicate was also demonstrated in a two-part trial with an open-label acute phase and a month-long randomized, double-blind, placebo-controlled withdrawal phase (Study 2; NCT02088073).
- In the open-label acute phase of Study 2, 258 patients with hyperkalemia (baseline mean 5.6 mEq/L, range 5.1 to 7.4 mEq/L) received 10 g of sodium zirconium cyclosilicate administered three times daily with meals for 48 hours. As shown in Figure 3, left, average serum potassium levels decreased from 5.6 to 4.5 mEq/L during treatment with sodium zirconium cyclosilicate in the acute phase.
- Following the acute phase of the study, there was a double-blind randomized withdrawal phase where patients who achieved potassium levels between 3.5 and 5 mEq/L were randomized to one of three doses of sodium zirconium cyclosilicate administered once-daily for 28 days, or placebo just before breakfast. Of the patients enrolled in the acute phase, 92% achieved a potassium level within this range and were enrolled into the second phase of the trial.
- The primary endpoint in the randomized withdrawal phase was the mean serum potassium value over the period from Day 8 to Day 29, comparing sodium zirconium cyclosilicate treated and placebo treated patients. All three doses (5, 10, and 15 g) of once daily sodium zirconium cyclosilicate maintained mean potassium at lower levels than placebo (mean serum potassium was 4.8, 4.5, and 4.4 mEq/L for the 5, 10, and 15 g dose groups, respectively, vs. 5.1 mEq/L in the placebo group, p0.001 for all doses, Figure 3, right). A greater proportion of patients had mean serum potassium levels in the normal range (3.5 to 5 mEq/L) while on sodium zirconium cyclosilicate than while on placebo (80%, 90%, and 94% at the 5, 10, and 15 g doses, respectively, vs. 46% on placebo).
- Patients who completed the 28-day randomized withdrawal phase had the option to continue treatment with sodium zirconium cyclosilicate, taken just before breakfast, in an open-label extension phase for up to 11 months (n=123; NCT02107092). Figure 4 shows that the treatment effect on serum potassium was maintained during continued therapy.
- Sodium zirconium cyclosilicate was evaluated in an open-label 12-month study in 751 hyperkalemic patients (NCT02163499). The mean baseline potassium level in this study was 5.6 mEq/L. Following the acute phase treatment of sodium zirconium cyclosilicate 10 g three times a day, patients who achieved normokalemia (3.5-5.0 mEq/L) within 72 hours (n=746; 99%) entered the maintenance phase. For maintenance treatment, the initial dosage of sodium zirconium cyclosilicate was 5 g once daily and was adjusted to a minimum of 5 g every other day up to maximum of 15 g once daily, based on serum potassium level. The treatment effect on serum potassium was maintained during continued therapy.

# How Supplied
- Sodium zirconium cyclosilicate (sodium zirconium cyclosilicate) for oral suspension is supplied as a white powder in foil-lined packets as follows:
- 5-g packet: Single (NDC 0310-1105-01) or box of 30 packets (NDC 0310-1105-30)
- 10-g packet: Single (NDC 0310-1110-01) or box of 30 packets (NDC 0310-1110-30)

## Storage
- Store sodium zirconium cyclosilicate at 15C-30C (59F-86F).

# Images

## Drug Images

## Package and Label Display Panel

# Patient Counseling Information
- Instruct the patient how to reconstitute sodium zirconium cyclosilicate for administration. Inform the patient that it is necessary to drink the full dose.
- Advise patients who are taking other oral medications to separate dosing of sodium zirconium cyclosilicate by at least 2 hours (before or after).
- Advise patients to adjust dietary sodium, if appropriate.

# Precautions with Alcohol
Alcohol-Sodium zirconium cyclosilicate interaction has not been established. Talk to your doctor regarding the effects of taking alcohol with this medication.

# Brand Names
- Lokelma

# Look-Alike Drug Names
There is limited information regarding Sodium zirconium cyclosilicate Look-Alike Drug Names in the drug label.

# Drug Shortage Status
Drug Shortage

# Price