What is the treatment for hyperkalemia (elevated potassium levels) in an elderly patient?

From the Guidelines

To treat hyperkalemia of 6.2 in an elderly patient, immediate intervention with intravenous calcium gluconate, insulin, and glucose is necessary to rapidly reduce the risk of cardiac arrhythmia and death. The patient should be assessed for ECG changes such as peaked T waves, widened QRS, or flattened P waves, and if cardiac manifestations are present, administer 10 mL of 10% calcium gluconate IV over 2-3 minutes for temporary cardiac membrane stabilization, as recommended by 1.

Next, shift potassium intracellularly with 10 units of regular insulin IV along with 25g of dextrose (50 mL of D50W) to prevent hypoglycemia, as supported by 1. Consider nebulized albuterol 10-20 mg as an additional shifting agent. For potassium removal, administer sodium polystyrene sulfonate (Kayexalate) 15-30g orally with sorbitol or patiromer 8.4g once daily, adjusting for elderly patients who may have reduced renal function.

Some key points to consider in the treatment of hyperkalemia in elderly patients include:

• Discontinuing potassium-sparing diuretics, ACE inhibitors, ARBs, and potassium supplements to prevent further potassium elevation
• Monitoring potassium levels every 2-4 hours initially, then daily until normalized
• Carefully monitoring for treatment complications including hypoglycemia from insulin, fluid overload from dextrose, and constipation or intestinal necrosis from potassium binders
• Identifying and addressing the underlying cause, such as medication effects, renal dysfunction, or acidosis, is crucial for preventing recurrence, as noted in 1 and 1.

The use of loop diuretics like furosemide 20-40mg IV can enhance potassium excretion if renal function permits, but careful consideration of the patient's renal function and potential for volume depletion is necessary. Overall, the goal of treatment is to rapidly reduce the risk of cardiac arrhythmia and death, and to identify and address the underlying cause of hyperkalemia to prevent recurrence.

From the FDA Drug Label

Veltassa is a potassium binder indicated for the treatment of hyperkalemia in adults and pediatric patients ages 12 years and older. For adults, the recommended starting dose of Veltassa is 8.4 grams administered orally once daily. For adults, adjust dose by 8.4 grams daily as needed at one-week intervals to obtain desired serum potassium target range. Veltassa should not be used as an emergency treatment for life-threatening hyperkalemia because of its delayed onset of action.

The patient has a hyperkalemia level of 6.2, which is elevated.

• The recommended starting dose of patiromer (Veltassa) for adults is 8.4 grams administered orally once daily 2.
• The dose can be adjusted by 8.4 grams daily as needed at one-week intervals to obtain the desired serum potassium target range 2.
• However, since the patient's hyperkalemia level is not considered life-threatening, patiromer (Veltassa) can be used for treatment.
• It is essential to monitor the patient's serum potassium levels and adjust the dose accordingly.
• Elderly patients should be treated with caution, and their condition should be closely monitored.
• Patiromer (Veltassa) should not be used as an emergency treatment for life-threatening hyperkalemia due to its delayed onset of action 2, 2.

From the Research

Treatment of Hyperkalemia

• 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 K+ from extracellular to intracellular stores, and to promote K+ excretion 3.
• For a potassium level of 6.2, urgent management may not be necessary unless ECG manifestations of hyperkalemia are present or severe muscle symptoms occur 4.

Medications for Hyperkalemia Treatment

• 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.
• New medications to promote gastrointestinal K+ excretion, which include patiromer and sodium zirconium cyclosilicate, hold promise 3, 5, 6.

Considerations for Elderly Patients

• Elderly subjects appear to be predisposed to the development of hyperkalemia on the basis of both innate disturbances in potassium homeostasis and comorbid disease processes that impair potassium handling 7.
• Hyperkalemia in the elderly is most often precipitated by medications that impair cellular uptake or renal disposal of potassium 7.
• Geriatric patients should be considered at risk of developing hyperkalemia, especially when they are prescribed certain medications, and potassium levels should be monitored at appropriate intervals 7.