From the Guidelines
Chronic hyperkalemia treatment should prioritize the use of potassium binders, such as patiromer or sodium zirconium cyclosilicate, in addition to dietary potassium restriction and addressing underlying causes, as these medications have been shown to effectively lower potassium levels and enable patients to continue renin-angiotensin-aldosterone system inhibitor (RAASi) therapy, which is crucial for reducing mortality and morbidity in patients with cardiovascular disease 1.
Key Considerations
- Dietary potassium restriction to 2-3 grams daily is essential in managing chronic hyperkalemia.
- Medication adjustments, such as discontinuing potassium-sparing diuretics, ACE inhibitors, or ARBs when possible, should be considered.
- Loop or thiazide diuretics, like furosemide 20-80 mg daily or hydrochlorothiazide 12.5-50 mg daily, can enhance potassium excretion in patients with adequate kidney function.
- Potassium binders, including sodium polystyrene sulfonate (15-60 g daily), patiromer (8.4-25.2 g daily), or sodium zirconium cyclosilicate (5-15 g daily), are effective in lowering potassium levels and preventing recurrences of hyperkalemia.
Monitoring and Treatment
- Regular monitoring of serum potassium levels is crucial, typically every 1-2 weeks initially, then monthly once stabilized.
- For patients with end-stage kidney disease, increasing dialysis frequency or adjusting the dialysate potassium concentration may be necessary.
- Treating metabolic acidosis with sodium bicarbonate 650-1300 mg three times daily can also help reduce potassium levels by shifting potassium into cells.
- The goal of therapy is to maintain serum potassium below 5.0 mEq/L while minimizing side effects such as hypokalemia, hypomagnesemia, or constipation that can occur with some treatments, as supported by recent clinical studies 2.
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
Chronic Hyperkalemia Treatment: Sodium polystyrene sulfonate can be used for the treatment of hyperkalemia, including chronic cases. The recommended dose is 15 g to 60 g per day, administered orally in divided doses.
- Key Considerations: + The drug has a delayed onset of action, making it unsuitable for emergency treatment of life-threatening hyperkalemia. + Patients should be monitored for signs of fluid overload, especially those sensitive to high sodium intake. + Other orally administered drugs should be taken at least 3 hours before or 3 hours after sodium polystyrene sulfonate. 3 4
From the Research
Treatment Options for Chronic Hyperkalemia
- Dietary management: A dietary potassium restriction of usually less than 3 g per day is recommended in the management of patients with reduced kidney function, especially those who tend to develop hyperkalaemia 5.
- Medications: Patiromer and sodium zirconium cyclosilicate (ZS9) are new agents designed to address the treatment gap in hyperkalemia, with a dose-dependent potassium-lowering effect and the ability to initiate, maintain, or titrate renin-angiotensin-aldosterone system inhibitors 6.
- Review of medications: The approach to patients with chronic hyperkalemia begins with a review of medications potentially responsible for the disorder, ensuring effective diuretic therapy and correcting metabolic acidosis if present 7.
Comparison of Treatment Options
- Patiromer vs Sodium Polystyrene Sulfonate: A study compared the potassium reduction of patiromer to sodium polystyrene sulfonate (SPS) within 6 to 24 hours following a single dose, and found that SPS had a higher mean potassium reduction than patiromer 8.
- K+ binding drugs: K+ binding drugs, such as patiromer and ZS9, can assist in maintaining the use of renin-angiotensin-aldosterone inhibitors, which improve outcomes in patients with heart failure and proteinuric kidney disease 7.
Diagnosis and Treatment Approach
- Diagnosis: Hyperkalemia results either from the shift of potassium out of cells or from abnormal renal potassium excretion, and can be caused by excessive intake of potassium, usually in the setting of impaired renal function 9.
- Treatment approach: The treatment approach for hyperkalemia includes stabilizing the cardiac membrane, shifting K+ into the cells, and ultimately initiating strategies to decrease total body K+ content, with a focus on correcting underlying causes and managing symptoms 7, 9.