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

From the Guidelines

Hyperkalemia treatment should prioritize the administration of intravenous calcium gluconate to rapidly stabilize cardiac membranes, followed by insulin and glucose to shift potassium into cells, as evidenced by the most recent and highest quality study 1.

Treatment Strategies

The management of hyperkalemia depends on the severity and urgency of the condition. For mild hyperkalemia, discontinuing potassium supplements and potassium-sparing medications may be sufficient. However, for moderate to severe hyperkalemia, more aggressive interventions are necessary.

• Stabilizing cardiac membranes with intravenous calcium gluconate (10 mL of 10% solution IV over 2-3 minutes) is crucial in severe cases to prevent arrhythmias, as noted in 1.
• Shifting potassium into cells can be achieved by administering insulin (10 units regular insulin IV) with glucose (25-50g IV) to prevent hypoglycemia, or nebulized albuterol (10-20 mg), as discussed in 1 and 1.
• Removing potassium from the body can be done using sodium polystyrene sulfonate (Kayexalate, 15-30g orally or rectally) or newer potassium binders like patiromer (8.4-25.2g daily) or sodium zirconium cyclosilicate (10g three times daily initially), as mentioned in 1.
• Loop diuretics like furosemide (40-80mg IV) can enhance renal potassium excretion in patients with adequate kidney function, as noted in 1 and 1.
• Hemodialysis is the most effective method for severe, refractory hyperkalemia, especially in patients with kidney failure, as highlighted in 1.

Key Considerations

• The symptoms of hyperkalemia can be nonspecific, and ECG findings can be highly variable and not as sensitive as a laboratory test in predicting hyperkalemia or its associated complications, as observed in 1.
• Treatment options for acute hyperkalemia include intravenous calcium gluconate, insulin/glucose, inhaled β-agonists, intravenous sodium bicarbonate, and hemodialysis, as discussed in 1 and 1.
• The REVEAL-ED study highlighted several deficiencies associated with current management of acute hyperkalemia, including a lack of standard, universally accepted treatment protocols or algorithms for managing hyperkalemia, as mentioned in 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

Sodium Polystyrene Sulfonate

• Sodium polystyrene sulfonate (SPS) is not efficacious for treating hyperkalemia 3
• SPS has been associated with bowel necrosis and other serious gastrointestinal adverse reactions 4, 5
• A retrospective study found that SPS reduced serum potassium levels by an average of 0.93 mEq/L, but was also associated with hypernatremia, hypokalemia, and bowel necrosis 4
• Another study found that SPS exhibited an advantage in treating hyperkalemia when used in small amounts, but cautioned against using high doses due to the risk of sodium loading 6

Alternative Treatments

• New medications to promote gastrointestinal potassium excretion, such as patiromer and sodium zirconium cyclosilicate, hold promise for treating hyperkalemia 3
• A prospective study found that sodium zirconium cyclosilicate (SZC) was more effective than calcium polystyrene sulfonate (CPS) in reducing serum potassium levels in patients with chronic hyperkalemia 7
• SZC achieved a higher percentage of patients with serum potassium levels below 5.3 mmol/L and below 6.0 mmol/L, with no serious adverse events attributable to the study drug 7