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

From the Guidelines

Mild hyperkalemia (serum potassium 5.1-5.9 mEq/L) should be treated with a combination of discontinuing medications that contribute to hyperkalemia, dietary potassium restriction, and oral potassium binders, with regular monitoring of serum potassium levels. The treatment approach for mild hyperkalemia depends on the patient's clinical status and the presence of underlying conditions such as cardiovascular disease, chronic kidney disease, or heart failure.

• Discontinuation of medications that may contribute to hyperkalemia, such as potassium supplements, potassium-sparing diuretics, ACE inhibitors, ARBs, and NSAIDs, is essential 1.
• Dietary potassium restriction to less than 2 grams per day is recommended to reduce potassium intake 1.
• Oral potassium binders like sodium polystyrene sulfonate (Kayexalate) 15-30 grams in 50-100 mL of sorbitol or patiromer 8.4 grams once daily can be used to remove potassium from the body 1.
• Loop diuretics such as furosemide 20-40 mg orally or intravenously can enhance potassium excretion in patients with normal renal function 1.
• For patients with metabolic acidosis, sodium bicarbonate 650 mg orally three times daily can help shift potassium into cells 1. Regular monitoring of serum potassium levels is essential during treatment, typically checking levels within 24-48 hours of initiating therapy 1. If hyperkalemia worsens or if the patient develops ECG changes or symptoms, more aggressive treatment for moderate to severe hyperkalemia would be necessary 1. The most recent study published in 2021 in the Mayo Clinic Proceedings 1 provides guidance on the clinical management of hyperkalemia, including the use of newer potassium-binding agents such as patiromer sorbitex calcium and sodium zirconium cyclosilicate, which may facilitate optimization of RAASi therapy.

From the FDA Drug Label

1 INDICATIONS AND USAGE Sodium Polystyrene Sulfonate Powder, for Suspension is indicated for the treatment of hyperkalemia.

• Treatment of hyperkalemia is indicated for polystyrene sulfonate (PO).
• However, the label states it should not be used as an emergency treatment for life-threatening hyperkalemia because of its delayed onset of action.
• The label does not explicitly address the treatment of mild hyperkalemia.
• Given the information, polystyrene sulfonate (PO) can be considered for the treatment of hyperkalemia, but caution is advised due to its delayed onset of action 2.

From the Research

Treatment of Mild Hyperkalemia

• The treatment of hyperkalemia involves measures to stabilize cardiac membranes, shift potassium from extracellular to intracellular stores, and promote potassium excretion 3.
• For mild hyperkalemia, treatment may include the use of insulin and glucose to shift potassium into cells, as well as the use of beta-agonists such as salbutamol to promote cellular uptake of potassium 4, 5.
• The use of sodium polystyrene sulfonate is not recommended, as it has been shown to be ineffective in treating hyperkalemia 3.
• Loop and thiazide diuretics may be useful in promoting potassium excretion, especially in patients with normal renal function 3.
• New medications such as patiromer and sodium zirconium cyclosilicate, which promote gastrointestinal potassium excretion, may also be effective in treating mild hyperkalemia 3.

Pharmacological Interventions

• Insulin and glucose are commonly used to treat hyperkalemia, with a mean reduction in serum potassium of 1.4 mmol/L 6.
• Salbutamol, either inhaled or intravenous, has been shown to be effective in reducing serum potassium levels, with a mean reduction of 0.7-1.2 mmol/L 4, 5.
• The use of bicarbonate has been shown to have no effect on potassium levels, and its use is not recommended 4, 5.
• Calcium gluconate or calcium chloride may be used to stabilize cardiac membranes, but there is limited evidence to support its use in treating hyperkalemia 3, 5.

Patient Factors and Cotreatments

• The efficacy of insulin-glucose treatment may be influenced by patient factors such as pre-treatment serum potassium level, with higher levels associated with a greater potassium-lowering effect 6.
• Cotreatment with sodium polystyrene sulfonate or sodium bicarbonate has not been shown to have a significant impact on the efficacy of insulin-glucose treatment 6.
• The use of salbutamol in combination with insulin-glucose treatment may result in an additional reduction in serum potassium, but the clinical significance of this effect is unclear 6.