How to treat hyperkalemia (elevated potassium levels)?

From the Guidelines

A potassium level of 8 mEq/L requires immediate treatment with calcium gluconate, insulin, and glucose to prevent life-threatening cardiac arrhythmias, as recommended by the most recent study 1. To manage severe hyperkalemia, the following steps should be taken:

• Obtain an ECG to assess for cardiac effects
• Administer calcium gluconate 10% solution (10 mL IV over 2-3 minutes) to stabilize cardiac membranes, which works within minutes but doesn't lower potassium levels
• Give insulin (10 units regular insulin IV) with glucose (25-50g IV) to shift potassium into cells, effective within 15-30 minutes and lasting several hours
• Simultaneously administer nebulized albuterol (10-20 mg) as another temporizing measure
• For potassium removal, consider sodium polystyrene sulfonate (15-30g orally or rectally) or patiromer (8.4g orally), though these work more slowly
• In severe cases, emergency hemodialysis may be necessary, as highlighted in the study 1 Key considerations in treating hyperkalemia include:
• Identifying and treating the underlying cause, which may include medication review (stopping ACE inhibitors, ARBs, potassium-sparing diuretics) 1
• Treating acidosis or addressing renal failure
• Continuous cardiac monitoring throughout treatment
• Frequent rechecking of potassium levels until normalized The study 1 emphasizes the importance of prompt treatment and highlights the potential benefits and limitations of various treatment options, including calcium gluconate, insulin, and glucose, as well as the role of hemodialysis in severe cases.

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)].

For a potassium level of 8, which is considered life-threatening hyperkalemia, the use of Sodium Polystyrene Sulfonate Powder, for Suspension is not recommended as an emergency treatment due to its delayed onset of action 2.

• The treatment for life-threatening hyperkalemia typically involves immediate interventions such as calcium gluconate, insulin, and glucose, or other rapid-acting treatments.
• Polystyrene sulfonate may be used as an adjunctive treatment after the initial correction of hyperkalemia, but not as the primary emergency treatment.

From the Research

Treatment of Hyperkalemia

To treat a potassium level of 8, the following steps can be taken:

• Stabilize cardiac membranes with calcium gluconate 10% dosed 10 mL intravenously, unless the patient is in cardiac arrest, in which case 10 mL calcium chloride is warranted 3
• Shift 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
• Administer dextrose as indicated by initial and serial serum glucose measurements 3
• Promote potassium excretion through dialysis, which is the most efficient means of removal 3
• Use loop and thiazide diuretics to promote potassium excretion 3
• Consider new medications that promote gastrointestinal potassium excretion, such as patiromer and sodium zirconium cyclosilicate 3, 4

Management Strategies

Management strategies for hyperkalemia may include:

• Reducing dietary potassium and discontinuing potassium supplements 4
• Withdrawal of exacerbating drugs 4
• Acute treatment with intravenous calcium gluconate, insulin, and glucose 4
• Nebulized albuterol 4
• Correction of acidosis with sodium bicarbonate for short-term shifts out of the plasma pool 4
• Gastrointestinal ion exchange with oral sodium polystyrene sulfonate in sorbitol, although this is poorly tolerated due to gastrointestinal adverse effects 4

Electrocardiogram Changes

Electrocardiogram (ECG) changes, especially widening of the QRS complexes, are important clues to the severity of hyperkalemia 5

• A treatment protocol based on ECG changes may reduce mortality in patients with hyperkalemia 5
• EKG changes should be rapidly antagonized by infusion of calcium salts 6

Pharmacologic Treatment

Pharmacologic treatment of chronic hyperkalemia in patients with chronic kidney disease may include:

• Potassium binders, such as sodium polystyrene sulfonate (SPS), calcium polystyrene sulfonate (CPS), patiromer, and sodium zirconium cyclosilicate (ZS-9) 7
• Long-term administration of a small dose of CPS may be effective and safe in the treatment of chronic hyperkalemia 7