From the Guidelines
Hyperkalemia treatment should prioritize immediate intervention with membrane stabilization using IV calcium gluconate, shifting potassium into cells with insulin and beta-2 agonists, and enhancing potassium elimination with loop diuretics and potassium binders, as recommended by the most recent and highest quality study 1.
Treatment Approach
The treatment approach for hyperkalemia involves:
- Membrane stabilization with IV calcium gluconate (1-2 ampules of 10% solution over 2-3 minutes) to reduce cardiac excitability
- Shifting potassium into cells using:
- Insulin (10 units regular insulin IV with 25g dextrose) to stimulate cellular uptake of potassium
- Inhaled beta-2 agonists (albuterol 10-20 mg nebulized) to increase cellular uptake of potassium
- Sodium bicarbonate (50 mEq IV if acidotic) to promote cellular uptake of potassium
- Enhancing potassium elimination with:
- Loop diuretics (furosemide 40-80 mg IV) to increase renal potassium excretion
- Potassium binders such as sodium polystyrene sulfonate (15-30g orally or rectally), patiromer (8.4-25.2g daily), or sodium zirconium cyclosilicate (10g three times daily initially, then 5-10g daily) to enhance fecal potassium excretion
Underlying Cause Management
Ongoing management requires addressing the underlying cause of hyperkalemia, which may include:
- Adjusting medications, such as discontinuing potassium-sparing medications or reducing the dose of renin-angiotensin-aldosterone system inhibitors
- Treating renal failure or correcting hormonal imbalances
- Monitoring patients with serial potassium measurements until levels normalize and remain stable, as recommended by the European Society of Cardiology 1 and the Mayo Clinic Proceedings 1.
Life-Threatening Hyperkalemia
For life-threatening hyperkalemia with ECG changes, emergent hemodialysis may be necessary, as recommended by the European Heart Journal 1.
From the FDA Drug Label
Sodium Polystyrene Sulfonate Powder, for Suspension is indicated for the treatment of hyperkalemia (1). Limitation of Use: Sodium Polystyrene Sulfonate Powder, for Suspension should not be used as an emergency treatment for life-threatening hyperkalemia because of its delayed onset of action (1)
Treatment of Hyperkalemia:
- Sodium Polystyrene Sulfonate Powder, for Suspension is indicated for the treatment of hyperkalemia.
- However, it should not be used as an emergency treatment for life-threatening hyperkalemia due to its delayed onset of action 2. Key Considerations:
- The average total daily adult dose is 15 g to 60 g, administered as a 15-g dose, one to four times daily.
- It is essential to monitor patients for signs of fluid overload, especially those sensitive to high sodium intake 2.
From the Research
Hyperkalemia Treatment Overview
- Hyperkalemia is a common electrolyte disorder that can result in morbidity and mortality if not managed appropriately 3
- Treatment includes measures to stabilize cardiac membranes, to shift potassium from extracellular to intracellular stores, and to promote potassium excretion 3
Stabilization of Cardiac Membranes
- Calcium gluconate 10% dosed 10 mL intravenously should be provided for membrane stabilization, unless the patient is in cardiac arrest, in which case 10 mL calcium chloride is warranted 3
- However, a systematic review and meta-analysis found no evidence to support a clinical beneficial effect of calcium for treatment of hyperkalemia 4
Shifting Potassium from Extracellular to Intracellular Stores
- Beta-agonists and intravenous insulin should be given to shift potassium from extracellular to intracellular stores 3
- Insulin and dextrose are frequently used to manage patients with hyperkalemia, but hypoglycemia after insulin use is a frequent complication 5
- Strategies to reduce the risk of hypoglycemia with insulin therapy include using insulin 5 units or 0.1 units/kg instead of 10 units, administering dextrose 50 g instead of 25 g, or administering dextrose as a prolonged infusion instead of a rapid intravenous bolus 5
Promotion of Potassium Excretion
- Dialysis is the most efficient means to enable removal of excess potassium 3
- Loop and thiazide diuretics can also be useful in promoting potassium excretion 3
- New medications to promote gastrointestinal potassium excretion, which include patiromer and sodium zirconium cyclosilicate, hold promise 3, 6