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Zirconium Cyclosilicate

Phase 3

Hyperkalemia | Small molecule | Other |AstraZeneca PLC|Last Updated: May 14, 2025

Success Probability
Approval Probability 71%
TA Base Rate26%
Adjusted LOA41%
ML RiskLOW_RISK
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Market & Valuation
rNPV $3.2B
Market Size $9.4B
Revenue Basis $1.6B
Competitors 6
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Trial Design
RandomizedDouble-BlindCONTROLLEDDMCBiomarker
Total Trials8
Total Enrollment1,212
FDA Designations
No designations recorded
Clinical Trials (8)
NCT IDTitlePhaseStatusEnrollmentVelocityDesignStartCompletionLast UpdatedSitesCountries
NCT03528681A Study to Investigate the Safety and Efficacy of ZS in Patients With Hyperkalemia.PHASE3 COMPLETED 270May 6, 2021Sep 15, 2022May 14, 202566 China, India
NCT04217590Reduce Incidence of Pre-Dialysis Hyperkalaemia With Sodium Zirconium Cyclosilicate in Chinese SubjectsPHASE3 COMPLETED 134Nov 16, 2020Jan 3, 2022Mar 28, 202336 China
NCT03303521A Study to Test Whether ZS (Sodium Zirconium Cyclosilicate) Can Reduce the Incidence of Increased Blood Potassium Levels Among Dialized Patients.PHASE3 COMPLETED 196Dec 14, 2017Nov 7, 2018Feb 20, 202053 United States, Japan +2
NCT03172702Open-label Safety of Sodium Zirconium Cyclosilicate for up to 12 Months in Japanese Subjects With HyperkalemiaPHASE3 COMPLETED 150Sep 4, 2017Jul 6, 2019May 1, 202042 Japan
NCT02875834A Study to Investigate the Safety and Efficacy of ZS in Patients With HyperkalemiaPHASE3 COMPLETED 267Mar 3, 2017Feb 14, 2018Aug 19, 202045 Japan, Russia +2
NCT03337477A Study to Evaluate a Potassium Normalization Treatment Regimen Including Sodium Zirconium Cyclosilicate (ZS) Among Patients With S-K ≥5.8PHASE2 COMPLETED 70Feb 13, 2018Dec 21, 2018Jan 28, 202025 United States, Denmark +2
NCT03127644ZS Ph2/3 Dose-response Study in JapanPHASE2 COMPLETED 103Jun 14, 2017Feb 23, 2018May 20, 201925 Japan
NCT03283267A Safety and Pharmacodynamic Study of Healthy Chinese Subjects Administered Sodium Zirconium Cyclosilicate (ZS)PHASE1 COMPLETED 22Oct 24, 2017Nov 23, 2017Dec 19, 20171 Hong Kong
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Study Endpoints
Primary Endpoints
Least Square Mean S-K Level on Days 8-29
Days 8 to 29 (Randomized treatment study phase) used for model-based least squares mean computation

Comparison between placebo and each SZC treatment group (high to low) with regard to the mean S-K level during the randomized treatment phase days 8-29. Mixed-effects models were used to estimate least-squares means.

Percentage of Responders
Evaluation period runs over the last 4 weeks of the treatment period up to 8 weeks.

A subject was considered to be a responder if, during the evaluation period, they maintained a pre-dialysis serum potassium (S-K) between 4.0 and 5.0 mmol/L on at least 3 out of 4 dialysis treatments following the long inter-dialytic interval (LIDI) and did not receive rescue therapy. Subjects with no data during the evaluation period were classified as non-responders. The S-K levels used for this analysis were based on the measurements obtained by the central laboratory.

Percentage of Responders When Accounting for Missing Central Laboratory Serum Potassium Data
Evaluation period runs over the last 4 weeks of the treatment period up to 8 weeks, starting after visit 11 and ending on visit 15, thus it comprises post-long inter-dialytic interval visits 12, 13, 14 and 15.

The sensitivity analysis assessed the impact of subjects classified as non-responders due to missing serum potassium (S-K) data. Missing central lab (c-lab) pre-dialysis values were imputed using corresponding pre-dialysis i-STAT (a portable blood analyser) measurements. In addition, a "last observation carried forward" (LOCF) approach was utilized to further impute missing values of pre-dialysis S-K during the evaluation period. This technique will replace missing c-lab S-K values with the last available non-missing pre-dialysis LIDI observation recorded for that patient (and this could be a c-lab value or an imputed c-lab value). The Primary endpoint analysis was repeated on the imputed data.

Number of Patients Who Experienced Adverse Events (AEs) in the MP
First MP dose up to 1 day (2 days for QOD regimen) after last MP dose.

The number of patients who experienced any AE, including those which were serious (SAE), had an outcome of death, were severe, led to discontinuation of ZS or were causally related to ZS are presented for the MP. AEs of special interest are also presented, including oedema-related AEs, cardiac failure and hypertension.

Mean Absolute Change in S-K From Baseline Until 4h After Start of Dosing With SZC/Placebo
Baseline to 4h potassium measurements.

The least squares means (LS-means) are derived from a linear regression model of absolute change in S-K at 4h with the following covariates: treatment group; baseline S-K; time from the start of dosing insulin to the start of dosing SZC/placebo and the dose (units/kg) of the first course of insulin. The 95% CI is associated with LS-Means.

Exponential Rate of Change in Serum Potassium (S-K) Values During the Initial 48 Hours of Study Drug Treatment
From 0 to 48 hours.

Blood samples for determination of potassium were collected pre-dose, and at 1, 2, and 4 hours post Dose 1 on Day 1. An additional sample was collected at 90 minutes post Dose 2 on Day 1 if i-STAT potassium values at the 4-hour post Dose 1 time point was ≥ 6.1 or \<4.0 mmol/L. On Day 2 samples were analysed pre-dose, and 1 and 4 hours post Dose 1. S-K levels were analysed at the Central Laboratory. Natural logarithm of S-K from 0 to 48 hours post dose are modelled by the random coefficients model including fixed effects of intercept, time, time x treatment and patient-level random effects for time and intercept. Exponential rate of change refers to the slope estimate from the random coefficients model.

Mean change from baseline to ZS treatment period in urine potassium excretion.
Study Day 3 and 4 vs Study Day 7 and 8.

The 48- hour urine potassium excretion on Study Days 3 and 4 (baseline) will be compared with 48-hour urine potassium excretion on Study Days 7 and 8 (on study drug).

Secondary Endpoints
Percentage of Patients Who Achieve Normokalemia
Through open label initial phase
Exponential Rate of Change in S-K Levels
Through 24 hours post-dose in the initial phase
Absolute Change From Baseline in S-K Levels
Through open label initial phase
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Study Design & Arms
AllocationRANDOMIZED
MaskingDOUBLE
ModelPARALLEL
PurposeTREATMENT
Treatment Arms
ArmTypeDescription
Sodium Zirconium Cyclosilicate 10gEXPERIMENTALSuspension administered 10g orally once daily for 28 days after the open label initial phase.
Sodium Zirconium Cyclosilicate 5gEXPERIMENTALSuspension administered 5g orally once daily for 28 days after the open label initial phase.
Matching PlaceboPLACEBO_COMPARATORSuspension administered orally placebo once daily for 28 days after the open label initial phase.
Sodium Zirconium Cyclosilicate (SZC)EXPERIMENTALSuspension administered orally for a treatment period of eight weeks (4 weeks of dose adjustment, 4 weeks in stable dose) Single dose contains from 1 to 3 sachets of SZC 5g depending on dose level assigned to a patient per non-dialysis days.
PlaceboPLACEBO_COMPARATORSuspension administered orally for a treatment period of eight weeks (4 weeks of dose adjustment, 4 weeks in stable dose) Single dose contains from 1 to 3 sachets of Placebo depending on dose level assigned to a patient per non-dialysis days.
Sodium Zirconium Cyclosilicate (ZS)EXPERIMENTALSuspension administered orally for a treatment period of eight weeks (4 weeks of dose adjustment, 4 weeks in stable dose) Single dose contains from 1 to 3 sachets of ZS 5g depending on dose level assigned to a patient per non-dialysis days.
Sodium Zirconium CyclosilicateEXPERIMENTALCorrection Phase Dosing: Sodium Zirconium Cyclosilicate 10 g three times daily (TID) from 24 to 72 Extended Dosing: Sodium Zirconium Cyclosilicate 5 g once daily (QD). Sodium Zirconium Cyclosilicate dose increased or decreased in increments/decrements of 5 g QD up to a maximum of 15 g QD or a minimum of 5 g every other day (QOD) (or 2.5 g QD) based on i-STAT potassium measurements up to 12 months.
Sodium Zirconium Cyclosilicate (ZS) 5gEXPERIMENTALSuspension administered 5g orally once daily for 28 days after the first 48-hour open label initial phase.
Sodium Zirconium Cyclosilicate (ZS) 10gEXPERIMENTALSuspension administered 10g orally once daily for 28 days after the first 48-hour open label initial phase.
ZS+insulin+glucoseEXPERIMENTALZS will be administered in addition to insulin and glucose. Insulin and glucose is the current standard of care to treat serum potassium ≥5.8mmol/L.
Placebo+insulin+glucosePLACEBO_COMPARATORPlacebo will be administered in addition to insulin and glucose. Insulin and glucose is the current standard of care to treat serum potassium ≥5.8mmol/L.
ZS 5g, qdEXPERIMENTALSubjects randomized to this arm will receive ZS 5 g qd in conjunction with breakfast during the ZS treatment period and will be continued with a standard diet.
ZS 10g, qdEXPERIMENTALSubjects randomized to this arm will receive ZS 10 g qd in conjunction with breakfast during the ZS treatment period and will be continued with a standard diet.
Interventions
NameTypeDescription
Sodium Zirconium Cyclosilicate 5gDRUGSuspension administered Sodium Zirconium Cyclosilicate 5g orally once daily for 28 days after the open label initial phase with suspension administered Sodium Zirconium Cyclosilicate 10g orally three times per day for at most 2 days.
Sodium Zirconium Cyclosilicate 10gDRUGSuspension administered Sodium Zirconium Cyclosilicate 10g orally once daily for 28 days after the open label initial phase with suspension administered Sodium Zirconium Cyclosilicate 10g orally three times per day for at most 2 days.
PlaceboDRUGSuspension administered orally placebo once daily for 28 days after the open label initial phase with suspension administered Sodium Zirconium Cyclosilicate 10g orally three times per day for at most 2 days.
Sodium Zirconium CyclosilicateDRUGSuspension administered orally for a treatment period of eight weeks (4 weeks of dose adjustment, 4 weeks in stable dose) Single dose contains from 1 to 3 sachets of SZC 5g depending on dose level assigned to a patient per non-dialysis days.
Sodium Zirconium Cyclosilicate (ZS)DRUGSuspension administered orally for a treatment period of eight weeks (4 weeks of dose adjustment, 4 weeks in stable dose) . Single dose contains from 1 to 3 sachets of ZS 5g depending on dose level assigned to a patient per non-dialysis days.
Zirconium CyclosilicateDRUGCorrection Phase Dosing: Sodium Zirconium Cyclosilicate 10 g three times daily (TID) from 24 to 72 Extended Dosing: Sodium Zirconium Cyclosilicate 5 g once daily (QD). Sodium Zirconium Cyclosilicate dose increased or decreased in increments/decrements of 5 g QD up to a maximum of 15 g QD or a minimum of 5 g every other day (QOD) (or 2.5 g QD) based on i-STAT potassium measurements up to 12 months.
Sodium Zirconium Cyclosilicate (ZS) 10gDRUGSuspension administered 10g orally three times per day, in the first 48-hour of the study for all patients (48-hour open label initial phase)
Sodium Zirconium Cyclosilicate (ZS) 5gDRUGSuspension administered 5g orally once daily for 28 days after the first 48-hour open label initial phase.
Sodium Zirconium Cyclosilicate(ZS)DRUGSuspension administered orally for a treatment period of 24h. Single dose contains 2 sachets of ZS 5g. 10g administered up to three times over 10h (at 0, 4 and 10h).
InsulinDRUGInsulin 0.1 units/kg administered as a bolus or for up to 30 minutes.
GlucoseDRUGGlucose 25g administered IV \<15 minutes before the insulin.
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Eligibility Criteria
Age Range18 Years — 90 Years
SexALL
Healthy VolunteersNo
Study Sites66

Inclusion Criteria: 1. Provision of informed consent (pre-screening consent) prior to any study specific procedures 2. Female and male patients aged ≥18 and ≤ 90 years 3. Provision of informed consent prior to any study specific procedures 4. Two consecutive i-STAT potassium values, measured 60 min...

Countries:ChinaIndiaUnited StatesJapanRussiaUnited KingdomSouth KoreaTaiwanDenmarkItalyHong Kong
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Competitive Landscape -Hyperkalemia 3 trials