How to manage hyperkalemia in patients with Diabetes Mellitus (DM)?

From the Guidelines

To treat hyperkalemia in diabetic patients, start by addressing the underlying cause while implementing immediate measures to lower potassium levels, prioritizing the use of newer potassium binders like patiromer or sodium zirconium cyclosilicate, as recommended by recent studies 1. For mild hyperkalemia (5.5-6.0 mEq/L), discontinue potassium-sparing medications, ACE inhibitors, ARBs, and potassium supplements. For moderate hyperkalemia (6.0-6.5 mEq/L), administer insulin with glucose: give 10 units of regular insulin IV with 25g of glucose (50 mL of D50W) to shift potassium intracellularly, as suggested by 1. This can be repeated as needed while monitoring blood glucose closely, especially in diabetic patients. For severe hyperkalemia (>6.5 mEq/L) with ECG changes, give calcium gluconate 10% (10 mL IV over 2-3 minutes) to stabilize cardiac membranes, followed by insulin/glucose therapy, as indicated by 1. Some key points to consider in the management of hyperkalemia include:

• The importance of monitoring serum potassium levels, especially in patients with chronic kidney disease, diabetes, heart failure, or a history of hyperkalemia, and those receiving RAASi therapy, as highlighted by 1.
• The use of loop diuretics like furosemide 40-80mg IV to enhance potassium excretion in patients with adequate kidney function, as mentioned in 1.
• The role of potassium binders, such as sodium polystyrene sulfonate (Kayexalate) 15-30g orally or rectally, patiromer (8.4-25.2g daily), or sodium zirconium cyclosilicate (10g TID for 48 hours, then 5-10g daily), in managing hyperkalemia, as discussed in 1.
• The need to address the underlying cause of hyperkalemia, such as optimizing diabetic kidney disease management or adjusting medications, for long-term management, as emphasized by 1. It is essential to individualize treatment and monitoring strategies based on the patient's specific clinical context and risk factors, as suggested by 1.

From the Research

Treatment of Hyperkalemia in Diabetic Patients

• Hyperkalemia is a common electrolyte disorder that can result in morbidity and mortality if not managed appropriately 2.
• Treatment of hyperkalemia includes measures to stabilize cardiac membranes, shift potassium from extracellular to intracellular stores, and promote potassium excretion 2.
• 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 2.
• Beta-agonists and intravenous insulin should be given, and some experts recommend the use of synthetic short-acting insulins rather than regular insulin 2.
• Dextrose should also be administered, as indicated by initial and serial serum glucose measurements 2.
• Dialysis is the most efficient means to enable removal of excess potassium 2.
• Loop and thiazide diuretics can also be useful in treating hyperkalemia 2.
• New medications to promote gastrointestinal potassium excretion, which include patiromer and sodium zirconium cyclosilicate, hold promise in the treatment of hyperkalemia 2, 3.

Considerations for Diabetic Patients

• Diabetic patients are at risk of developing hyperkalemia due to their underlying medical condition 3.
• Insulin and glucose are frequently used to manage patients with hyperkalemia, but hypoglycemia after insulin use is a frequent complication 4.
• 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 4.
• Patients receiving insulin for hyperkalemia should be monitored for hypoglycemia hourly for at least 4-6 hours after administration 4.

Additional Therapies

• Sodium polystyrene sulfonate is not efficacious in the treatment of hyperkalemia 2.
• Patiromer and sodium zirconium cyclosilicate are new medications that can aid in the reduction of serum potassium levels 3.
• These medications have unique benefits and contraindications, and clinicians must be aware of them when managing patients with hyperkalemia 3.
• Continuous infusion of a solution containing fixed concentrations of calcium gluconate, insulin, dextrose, and sodium acetate (HyperK-Cocktail) has been shown to be safe and effective in the treatment of hyperkalemia 5.