What is the best beta (β) agonist to administer for hyperkalemia?

From the Guidelines

Albuterol (salbutamol) is the preferred beta agonist for treating hyperkalemia, as it effectively reduces serum potassium levels by stimulating beta-2 adrenergic receptors and activating the sodium-potassium ATPase pump. The recommended dose is 10-20 mg via nebulizer over 10 minutes, which can be repeated if necessary, as supported by recent clinical guidelines 1. This treatment option is particularly useful in emergency situations, as it acts quickly to lower serum potassium levels, with effects beginning within 30 minutes and lasting for 2-4 hours, reducing potassium levels by approximately 0.5-1.0 mEq/L.

Key Considerations

• Albuterol provides only temporary potassium redistribution rather than elimination from the body, so definitive treatment addressing the underlying cause of hyperkalemia must follow 1.
• Albuterol is generally well-tolerated but may cause tachycardia, tremors, and anxiety, so monitoring vital signs during administration is recommended, especially in patients with cardiovascular disease.
• The use of albuterol in treating hyperkalemia is supported by recent studies, including those published in the Mayo Clinic Proceedings 1, which highlight its effectiveness in rapidly reducing serum potassium levels.

Treatment Approach

• Intravenous calcium gluconate may be administered concurrently to rapidly reduce the membrane excitatory effects of potassium on cardiac tissue 1.
• Insulin and glucose may also be used to promote potassium redistribution into the intracellular space, but glucose must be administered with insulin to prevent hypoglycemia 1.
• Hemodialysis may be used as an adjunctive therapy in acute hyperkalemia after instituting other approaches, particularly in patients with severe hyperkalemia or those who are resistant to other treatments 1.

From the FDA Drug Label

The FDA drug label does not answer the question.

From the Research

Beta Agonists for Hyperkalemia

• The most commonly used beta agonist for hyperkalemia is salbutamol (also known as albuterol) 2, 3, 4, 5.
• Salbutamol can be administered via nebulizer or metered-dose inhaler (MDI) and has been shown to significantly reduce serum potassium levels 4, 5.
• The peak effect of nebulised salbutamol is seen at 120 minutes, with a mean difference (MD) of -1.29 mmol/L (95% CI -1.64 to -0.94) 4.
• Salbutamol has been compared to other interventions, including insulin-dextrose, and has been found to have a similar effect 4.
• The combination of salbutamol with insulin-dextrose may be more effective than either alone in reducing serum potassium levels 5.

Comparison of Beta Agonists

• There is limited evidence to support the use of other beta agonists, such as terbutaline or metaproterenol, in the management of hyperkalemia 4, 5.
• Salbutamol is the most well-studied beta agonist for hyperkalemia and is considered the first-line therapy 4, 5.

Clinical Use of Beta Agonists

• Beta agonists, such as salbutamol, should be used in conjunction with other therapies, including insulin-dextrose and calcium salts, to manage hyperkalemia 2, 3, 5.
• The dose and administration route of salbutamol may vary depending on the clinical situation and patient factors 4, 5.
• Further research is needed to establish optimal dosing strategies for beta agonists in the management of hyperkalemia 6.