What are the recommendations for managing hyperkalemia (elevated potassium levels)?

From the Guidelines

For elevated potassium (hyperkalemia), I recommend immediate medical attention if levels exceed 6.0 mmol/L or if symptoms like muscle weakness or irregular heartbeat are present, as stated in the most recent and highest quality study 1. To lower potassium levels, the following steps can be taken:

• Reduce dietary potassium by limiting foods like bananas, oranges, potatoes, tomatoes, and leafy greens.
• Increase fluid intake unless contraindicated by other conditions.
• For mild to moderate hyperkalemia (5.0-6.0 mmol/L), oral sodium polystyrene sulfonate (Kayexalate) 15g 1-4 times daily or patiromer (Veltassa) 8.4g daily may be prescribed, as suggested by 1.
• For severe cases, emergency treatments include:
  • Calcium gluconate 10% (10mL IV over 2-3 minutes) to stabilize cardiac membranes, as recommended by 1.
  • Insulin with glucose (10 units regular insulin with 25g dextrose IV), as stated in 1.
  • Nebulized albuterol (10-20mg), as mentioned in 1.
• Loop diuretics like furosemide may help if kidney function is adequate, as noted in 1.
• Discontinue medications that can raise potassium, including ACE inhibitors, ARBs, potassium-sparing diuretics, and NSAIDs, as advised by 1. Regular monitoring of potassium levels is essential during treatment, as emphasized by 1. Hyperkalemia is dangerous because excess potassium disrupts electrical signaling in the heart, potentially causing life-threatening arrhythmias.

From the FDA Drug Label

The intensity and duration of therapy depend upon the severity and resistance of hyperkalemia. Oral The average total daily adult dose of Sodium Polystyrene Sulfonate Powder, for Suspension is 15 g to 60 g, administered as a 15-g dose (four level teaspoons), one to four times daily. Rectal The average adult dose is 30 g to 50 g every six hours.

For elevated potassium levels, the recommended dosage of Sodium Polystyrene Sulfonate Powder, for Suspension is:

• Oral: 15 g to 60 g per day, administered as 15-g doses, one to four times daily 2
• Rectal: 30 g to 50 g every six hours 2 Key considerations:
• The intensity and duration of therapy depend on the severity and resistance of hyperkalemia.
• Monitor serum potassium during therapy because severe hypokalemia may occur 2.

From the Research

Elevated Potassium Recommendations

• The management of hyperkalemia involves stabilizing cardiac membrane potentials, reducing serum potassium levels, and eliminating potassium through excretion 3, 4.
• Treatment options include:
  • Calcium gluconate or calcium chloride to stabilize cardiac membranes 3, 5
  • Intravenous insulin and glucose to shift potassium into cells 3, 4, 5
  • Nebulized β-2 adrenoceptor agonists to augment the effects of insulin and glucose 4, 5
  • Loop and thiazide diuretics to promote potassium excretion 3
  • Sodium zirconium cyclosilicate and patiromer to promote gastrointestinal potassium excretion 3, 6
• Sodium polystyrene sulfonate is not recommended due to its limited efficacy 3, 6
• Dialysis is the most efficient means of removing excess potassium 3
• The choice of treatment depends on the severity of hyperkalemia, the presence of ECG changes, and the underlying cause of the condition 4, 5
• It is essential to monitor serum potassium levels closely and adjust treatment accordingly 6, 5
• Further research is needed to establish optimal strategies for managing acute hyperkalemia in the emergency department 4