What is the treatment for hyperkalemia?

From the Guidelines

The treatment for hyperkalemia should prioritize the use of calcium gluconate, insulin with glucose, and potassium binders like patiromer or sodium zirconium cyclosilicate, as these interventions have been shown to effectively manage hyperkalemia and improve patient outcomes, as supported by the most recent and highest quality study 1.

Causes of Hyperkalemia

The causes of hyperkalemia can be categorized into two main groups:

• Decreased potassium excretion, which can be caused by medications such as potassium-sparing diuretics, beta-blockers, NSAIDs, and renin-angiotensin-aldosterone inhibitors, as well as certain medical conditions like kidney disease 1.
• Increased potassium intake or administration, which can occur through dietary sources, potassium supplements, or certain medications like penicillin G 1.

Treatment Approaches

The treatment of hyperkalemia involves several approaches, including:

• Protecting against cardiac effects with calcium gluconate or calcium chloride 1
• Shifting potassium into cells temporarily with insulin and glucose, or beta-agonists like albuterol 1
• Removing excess potassium from the body with loop diuretics, potassium binders like sodium polystyrene sulfonate, patiromer, or sodium zirconium cyclosilicate, or hemodialysis in severe cases 1

Key Considerations

When managing hyperkalemia, it is essential to consider the severity of the condition, the patient's kidney function, and the presence of any underlying medical conditions.

• In patients with mild hyperkalemia, dietary potassium restriction and discontinuation of medications that increase potassium levels may be sufficient 1.
• In patients with moderate to severe hyperkalemia, more urgent interventions like calcium gluconate, insulin with glucose, and potassium binders are necessary 1.
• Regular monitoring of potassium levels is crucial, especially in patients treated with renin-angiotensin-aldosterone inhibitors, to prevent and manage hyperkalemia effectively 1.

From the FDA Drug Label

Sodium Polystyrene Sulfonate Powder, for Suspension is indicated for the treatment of hyperkalemia (1). Limitation of Use: Sodium Polystyrene Sulfonate Powder, for Suspension should not be used as an emergency treatment for life-threatening hyperkalemia because of its delayed onset of action (1).

The treatment for hyperkalemia is Sodium Polystyrene Sulfonate Powder, for Suspension 2. However, it should not be used as an emergency treatment for life-threatening hyperkalemia due to its delayed onset of action.

• Key points:
  • Indicated for hyperkalemia treatment
  • Not for emergency treatment of life-threatening hyperkalemia
  • Delayed onset of action 2

From the Research

Cause of Hyperkalemia

• Hyperkalemia results from the shift of potassium out of cells or from abnormal renal potassium excretion 3
• Cell shift leads to transient increases in the plasma potassium concentration, whereas decreased renal excretion of potassium leads to sustained hyperkalemia 3
• Impairments in renal potassium excretion can be the result of reduced sodium delivery to the distal nephron, decreased mineralocorticoid level or activity, or abnormalities in the cortical collecting duct 3
• Excessive intake of potassium can cause hyperkalemia but usually in the setting of impaired renal function 3

Treatment of Hyperkalemia

• Treatment includes measures to stabilize cardiac membranes, to shift K+ from extracellular to intracellular stores, and to promote K+ excretion 4
• 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 4
• Beta-agonists and intravenous insulin should be given, and some experts recommend the use of synthetic short-acting insulins rather than regular insulin 4
• Dextrose should also be administered, as indicated by initial and serial serum glucose measurements 4
• Dialysis is the most efficient means to enable removal of excess K+ 4
• Loop and thiazide diuretics can also be useful 4
• New medications to promote gastrointestinal K+ excretion, which include patiromer and sodium zirconium cyclosilicate, hold promise 4, 5
• Salbutamol administered via either nebulizer or metered-dose inhaler (MDI) significantly reduced serum potassium compared with placebo 6
• Insulin-dextrose was more effective than IV bicarbonate and aminophylline 6

Management of Hyperkalemia

• 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
• The practice of restricting foods high in K+ to manage hyperkalemia is being reassessed since the evidence supporting the effectiveness of this strategy is lacking 7
• Rather, dietary restriction should be more nuanced, focusing on reducing the intake of nonplant sources of K+ 7
• K+ binding drugs and sodium-glucose cotransporter 2 inhibitors can assist in maintaining the use of these drugs 7
• Hyperkalemia should be monitored closely for high-risk patients, as it is associated with adverse outcomes 5