From the Guidelines
Hyperkalemia treatment should prioritize immediate intervention with calcium gluconate, insulin, and glucose to stabilize cardiac membranes and shift potassium intracellularly, followed by potassium removal strategies such as loop diuretics, sodium polystyrene sulfonate, or hemodialysis, as recommended by the most recent and highest quality study 1.
Treatment Approach
The treatment of hyperkalemia depends on the severity of the condition and the presence of ECG changes or muscle weakness. For mild hyperkalemia, dietary potassium restriction and discontinuation of potassium-sparing medications may be sufficient. However, for moderate to severe hyperkalemia, immediate intervention is necessary to prevent cardiac arrhythmias and other complications.
Acute Management
The acute management of hyperkalemia involves several strategies, including:
- Cardiac membrane stabilization: Calcium gluconate (10%, 10-20 mL IV over 2-5 minutes) should be administered first to stabilize cardiac membranes and prevent arrhythmias, particularly if ECG changes are present 1.
- Intracellular potassium shift: Insulin with glucose (10 units regular insulin with 25g dextrose IV) shifts potassium intracellularly within 15-30 minutes, lasting 4-6 hours 1.
- Potassium removal: Loop diuretics like furosemide (40-80mg IV) increase renal potassium excretion in patients with adequate kidney function, while sodium polystyrene sulfonate (15-30g orally or rectally) exchanges sodium for potassium in the gut 1.
- Hemodialysis: Hemodialysis remains the most effective method for severe or refractory hyperkalemia, especially in patients with kidney failure 1.
Underlying Cause
After acute management, addressing the underlying cause of hyperkalemia is essential to prevent recurrence, which may involve medication adjustments, treating hormonal imbalances, or managing kidney disease 1. Regular monitoring of potassium levels is crucial, especially in patients treated with renin-angiotensin-aldosterone system inhibitors (RAASi) 1.
Key Considerations
- The incidence of hyperkalemia can be as high as 50% in unselected populations of patients receiving RAASi 1.
- Quality improvement programs are needed to improve rates of laboratory monitoring for patients initiated on MRA therapy, particularly in high-risk patients 1.
- The clinical benefit of spironolactone and eplerenone remains even in those who develop modest elevations in K+ level 1.
From the FDA Drug Label
1 INDICATIONS AND USAGE Sodium Polystyrene Sulfonate Powder, for Suspension is indicated for the treatment of hyperkalemia. 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 [see Clinical Pharmacology (12.2)].
- Treatment of hyperkalemia: Polystyrene sulfonate (PO) is indicated for the treatment of hyperkalemia.
- Limitation: It should not be used as an emergency treatment for life-threatening hyperkalemia due to its delayed onset of action 2.
From the Research
Treatment Options for Hyperkalemia
- Membrane stabilization using calcium gluconate 10% dosed 10 mL intravenously, unless the patient is in cardiac arrest, in which case 10 mL calcium chloride is warranted 3
- Shifting potassium from extracellular to intracellular stores using beta-agonists and intravenous insulin, with some experts recommending the use of synthetic short-acting insulins rather than regular insulin 3
- Promoting potassium excretion through dialysis, loop and thiazide diuretics, and new medications such as patiromer and sodium zirconium cyclosilicate 3, 4
- Administering glucose and insulin, bicarbonate, calcium gluconate, beta-2 agonists, hyperventilation, and dialysis in acute and potentially lethal conditions 4
Pharmacotherapies for Hyperkalemia
- Sodium polystyrene sulfonate (SPS), sodium zirconium cyclosilicate (SZC), and patiromer, which have increased selectivity for potassium and work primarily in the gastrointestinal (GI) tract 4
- Insulin and glucose, which are frequently used to manage patients with hyperkalemia, but require careful monitoring for hypoglycemia 5
- Beta-2 agonists, such as albuterol, which can be used to lower serum potassium levels in the acute setting 6
Considerations for Treatment
- Determining the need for urgent treatment through a combination of history, physical examination, laboratory, and electrocardiography findings 6
- Considering potential causes of transcellular shifts, as patients are at increased risk of rebound potassium disturbances 6
- Monitoring for hypoglycemia hourly for at least 4-6 hours after administration of insulin for hyperkalemia 5