What is the treatment for hyperkalemia (elevated potassium levels)?

From the Guidelines

Hyperkalemia treatment should prioritize the administration of intravenous calcium gluconate to rapidly reduce the membrane excitatory effects of potassium on cardiac tissue, followed by insulin/glucose and inhaled β-agonists to promote redistribution of serum potassium into the intracellular space, as recommended by the most recent and highest quality study 1.

Treatment Approaches

The management of hyperkalemia depends on the severity of the condition and the presence of electrocardiographic changes. The following treatment options are available:

• Intravenous calcium gluconate: administered to rapidly reduce the membrane excitatory effects of potassium on cardiac tissue within 1 to 3 minutes, thereby minimizing the potential for cardiac arrhythmia 1.
• Insulin/glucose: acts within 30 minutes to promote redistribution of serum potassium into the intracellular space, but does not change total body potassium levels 1.
• Inhaled β-agonists: also acts within 30 minutes to promote redistribution of serum potassium into the intracellular space, but has a short duration of effect of 2 to 4 hours 1.
• Sodium bicarbonate: may be used to promote potassium excretion in patients with concurrent metabolic acidosis, but its use is limited to these patients 1.
• Hemodialysis: increases potassium elimination from the body and may be used as an adjunctive therapy in acute hyperkalemia after instituting other approaches 1.

Key Considerations

When managing hyperkalemia, it is essential to consider the following:

• The symptoms of hyperkalemia can be nonspecific, and electrocardiographic findings can be highly variable and not as sensitive as a laboratory test in predicting hyperkalemia or its associated complications 1.
• The treatment of hyperkalemia should be individualized based on the severity of the condition, the presence of electrocardiographic changes, and the underlying cause of the hyperkalemia.
• Ongoing monitoring of potassium levels, cardiac function, and addressing the underlying cause are essential components of comprehensive hyperkalemia management 1.

From the FDA Drug Label

Sodium polystyrene sulfonate is a potassium binder indicated for the treatment of hyperkalemia Limitation of Use: Sodium polystyrene sulfonate should not be used an emergency treatment for life threatening hyperkalemia because of its delayed onset of action. The average total daily adult dose of sodium polystyrene sulfonate is 15 g to 60 g, administered as a 15 g dose (four level teaspoons), one to four times daily The average adult dose is 30 g to 50 g every six hours

Treatment of Hyperkalemia: Sodium polystyrene sulfonate is indicated for the treatment of hyperkalemia.

• The recommended oral dose is 15 g to 60 g per day, administered in 15 g doses, one to four times daily.
• The recommended rectal dose is 30 g to 50 g every six hours. However, it should not be used as an emergency treatment for life-threatening hyperkalemia due to its delayed onset of action 2 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

Treatment Measures

• 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
• Beta-agonists and intravenous insulin should be given, and some experts recommend the use of synthetic short-acting insulins rather than regular insulin 3
• Dextrose should also be administered, as indicated by initial and serial serum glucose measurements 3
• Dialysis is the most efficient means to enable removal of excess potassium 3
• Loop and thiazide diuretics can also be useful 3

Potassium Binders

• Sodium polystyrene sulfonate (SPS) is not efficacious 3 and its use may be associated with harm, including bowel necrosis 4
• New medications to promote gastrointestinal potassium excretion, which include patiromer and sodium zirconium cyclosilicate, hold promise 3, 5
• Calcium polystyrene sulfonate (CPS) has the advantage of avoiding hypervolemia because it exchanges calcium for potassium 5
• Sodium zirconium cyclosilicate (SZC) demonstrated superior effectiveness in reducing potassium levels and controlling severe hyperkalemia in patients undergoing maintenance hemodialysis 6

Comparison of Potassium Binders

• A study compared the efficacy and safety of SZC and CPS in hemodialysis patients with hyperkalemia, and found that SZC achieved a higher percentage of patients exhibiting serum potassium levels below 6.0 mmol/L at the 2-week timepoint 6
• Another study found that Na-resin exhibited an advantage in treating hyperkalemia when used in small amounts, but physicians should select the type and amount of resin according to the sodium and/or calcium load in each case 7