1 Recommendations

1.1 Sodium zirconium cyclosilicate is recommended as an option for treating hyperkalaemia in adults only if used:

  • in emergency care for acute life-threatening hyperkalaemia alongside standard care or

  • for people with persistent hyperkalaemia and chronic kidney disease stage 3b to 5 or heart failure, if they:

    • have a confirmed serum potassium level of at least 6.0 mmol/litre and

    • because of hyperkalaemia, are not taking an optimised dosage of renin-angiotensin-aldosterone system (RAAS) inhibitor and

    • are not on dialysis. [amended 2022]

1.2 Stop sodium zirconium cyclosilicate if RAAS inhibitors are no longer suitable. [amended 2022]

1.3 This recommendation is not intended to affect treatment with sodium zirconium cyclosilicate that was started in the NHS before this guidance was published. People having treatment outside this recommendation may continue without change to the funding arrangements in place for them before this guidance was published, until they and their NHS clinician consider it appropriate to stop.

Why the committee made these recommendations

Sodium zirconium cyclosilicate is a treatment for people with high blood potassium levels (hyperkalaemia). It may benefit adults with chronic kidney disease or heart failure, either:

  • in emergency care for life-threatening hyperkalaemia or

  • for persistent hyperkalaemia that prevents people from having an optimised dose of RAAS inhibitors.

Treating acute life-threatening hyperkalaemia in emergency care is established clinical practice. Evidence from people with hyperkalaemia having treatment in outpatient care suggests that sodium zirconium cyclosilicate could be a useful addition to emergency care. Other potassium-lowering treatments are rarely used in this setting because they are poorly tolerated.

The cost-effectiveness estimates for sodium zirconium cyclosilicate suggest that it is a good use of NHS resources for treating acute life-threatening hyperkalaemia in emergency care. Therefore, it is recommended.

Clinical trials show that sodium zirconium cyclosilicate lowers serum potassium when used in outpatient care. But there is no clinical evidence that it extends life or improves quality of life. Sodium zirconium cyclosilicate may allow people to stay on RAAS inhibitors (drugs used to treat heart failure and kidney disease) for longer. Staying on these drugs may extend life and improve quality of life.

Considering the benefit from more people being able to stay on RAAS inhibitors, the cost-effectiveness estimates for sodium zirconium cyclosilicate suggest that it is a good use of NHS resources. Therefore, it is recommended for treating confirmed persistent hyperkalaemia when started in specialist care, for people who are not taking an optimised dose of RAAS inhibitors because of hyperkalaemia.

  • National Institute for Health and Care Excellence (NICE)