From the Guidelines
For the management of hyperkalemia, the most effective treatment approach includes immediate interventions such as calcium gluconate, insulin-glucose therapy, and nebulized albuterol, with hemodialysis being the most effective method for severe or refractory cases, as supported by the most recent and highest quality study 1.
Treatment Options
The treatment of hyperkalemia depends on the severity of the condition and the patient's clinical status. For mild to moderate hyperkalemia, oral potassium binders such as sodium polystyrene sulfonate (Kayexalate) 15-30g orally every 6 hours or patiromer (Veltassa) 8.4g daily can be effective. Loop diuretics like furosemide 40-80mg IV or orally can increase potassium excretion through the kidneys.
Severe Hyperkalemia Management
For severe hyperkalemia (>6.5 mEq/L), immediate interventions are crucial and include:
- Calcium gluconate 10% solution (10mL IV over 2-3 minutes) to stabilize cardiac membranes
- Insulin-glucose therapy (10 units regular insulin IV with 25g dextrose) to shift potassium intracellularly
- Nebulized albuterol 10-20mg to promote cellular potassium uptake
- Sodium bicarbonate 50 mEq IV over 5 minutes may help in acidotic patients
Most Effective Method
Hemodialysis remains the most effective method for severe or refractory hyperkalemia, as it directly removes potassium from the bloodstream, thereby rapidly reducing serum potassium levels 1.
Choice of Therapy
The choice of therapy depends on the severity of hyperkalemia, the patient's clinical status, and the underlying cause of the elevated potassium. It is essential to individualize treatment and monitoring strategies, especially for patients with chronic kidney disease, diabetes, heart failure, or a history of hyperkalemia, and for those receiving renin-angiotensin-aldosterone system inhibitor (RAASi) therapy 1.
From the FDA Drug Label
1 INDICATIONS AND USAGE Sodium Polystyrene Sulfonate Powder, for Suspension is indicated for the treatment of hyperkalemia.
CLINICAL STUDIES Medical literature also refers to the administration of calcium chloride in the treatment of magnesium intoxication due to overdosage of magnesium sulfate, and to combat the deleterious effects of hyperkalemia as measured by electrocardiogram (ECG), pending correction of the increased potassium level in the extracellular fluid.
- Antihyperkalemic measures include the use of sodium polystyrene sulfonate and calcium chloride.
- Sodium polystyrene sulfonate is indicated for the treatment of hyperkalemia 2.
- Calcium chloride is used to combat the deleterious effects of hyperkalemia pending correction of the increased potassium level in the extracellular fluid 3.
From the Research
Antihyperkalemic Measures
- Treatment of hyperkalemia includes measures to stabilize cardiac membranes, shift potassium from extracellular to intracellular stores, and promote potassium excretion 4
- 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 4
- Beta-agonists and intravenous insulin should be given, and some experts recommend the use of synthetic short-acting insulins rather than regular insulin 4
- Dextrose should also be administered, as indicated by initial and serial serum glucose measurements 4
- Dialysis is the most efficient means to enable removal of excess potassium 4
- Loop and thiazide diuretics can also be useful 4
- Sodium polystyrene sulfonate is not efficacious 4
- New medications to promote gastrointestinal potassium excretion, which include patiromer and sodium zirconium cyclosilicate, hold promise 4
Effectiveness of Calcium Gluconate
- IV calcium gluconate therapy was found to be effective, albeit to a limited degree, in main rhythm ECG disorders due to hyperkalemia, but it was not found to be effective in nonrhythm ECG disorders due to hyperkalemia 5
- Calcium gluconate may be effective only in the main rhythm disorders due to hyperkalemia 5
Management of Hyperkalemia with Insulin and Glucose
- Insulin and dextrose are frequently used to manage patients with hyperkalemia 6
- Hypoglycemia after insulin use is a frequent complication during hyperkalemia management 6
- Several strategies can reduce the risk of hypoglycemia with insulin therapy, which 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 6
- Patients receiving insulin for hyperkalemia should be monitored for hypoglycemia hourly for at least 4-6 h after administration 6