What medication(s) should be given to a patient with hyperkalaemia?

Treatment of Elevated Potassium (Hyperkalemia)

For acute hyperkalemia, immediately administer IV calcium (10 mL of 10% calcium gluconate) if ECG changes are present or potassium ≥6.5 mEq/L, followed by insulin/glucose (10 units insulin + 50 mL dextrose) and nebulized salbutamol (20 mg in 4 mL) to shift potassium intracellularly. 1

Acute Management Algorithm

Immediate Stabilization (Within 1-3 minutes)

• IV Calcium: 10 mL of 10% calcium gluconate
  • Reduces cardiac membrane excitability
  • Indicated when: ECG changes present OR serum K+ ≥6.5 mEq/L
  • Does NOT lower total body potassium 1

Intracellular Shift (30-60 minutes onset)

• Insulin/Glucose: 10 units regular insulin + 50 mL dextrose

  • Primary agent for shifting K+ intracellularly
  • Critical pitfall: Monitor for hypoglycemia, especially in non-diabetics with low baseline glucose 1, 2

• Nebulized Salbutamol: 20 mg in 4 mL

  • Synergistic effect with insulin
  • Duration only 2-4 hours
  • Should be used in combination, not as monotherapy 1, 2

• Sodium Bicarbonate: Only if metabolic acidosis present

  • Not routinely recommended
  • Limited to specific acidotic patients 1

Potassium Elimination

• Diuretics: If hypervolemic and non-oliguric 1

• Hemodialysis: If oliguria or end-stage renal disease, or resistant acute hyperkalemia 1

Chronic Management

Potassium Binders

For chronic hyperkalemia, newer potassium binders (sodium zirconium cyclosilicate or patiromer) are preferred over sodium polystyrene sulfonate to enable continuation of life-saving RAAS inhibitor therapy. 1

Sodium Zirconium Cyclosilicate (SZC/Lokelma)

• Onset: 1 hour (fastest)
• Dosing: 10g TID for 48 hours, then 5g every other day to 15g daily for maintenance
• Advantages: Highly selective for K+, works in small and large intestines
• Considerations: Contains 400mg sodium per 5g dose 1

Patiromer

• Onset: 7 hours
• Dosing: 8.4g once daily, titrate up to 25.2g daily
• Advantages: No sodium content, no serious adverse events reported
• Considerations: Contains 1.6g calcium per dose, separate from other oral medications 1

Sodium Polystyrene Sulfonate (SPS/Kayexalate)

• NOT recommended due to:
  • Variable/inconsistent efficacy
  • Fatal GI injuries reported (intestinal ischemia, colonic necrosis)
  • 33% mortality rate in some reports
  • Doubles risk of serious GI adverse events 1, 3, 2

Critical Management Principle

Do NOT discontinue or reduce RAAS inhibitors (ACE inhibitors, ARBs, MRAs) for hyperkalemia. 4, 1

The 2025 European guidelines emphasize that RAAS inhibitor withdrawal is associated with:

• Increased mortality
• Heart failure hospitalizations
• Progression to end-stage kidney disease 4

Instead: Treat hyperkalemia with potassium binders to enable continuation of maximum tolerated RAAS inhibitor doses, which reduce disease progression and mortality 4, 1

Monitoring Strategy

• Check K+ within 1 week after starting or escalating RAAS inhibitors 1
• More frequent monitoring in high-risk patients (CKD, diabetes, heart failure, history of hyperkalemia) 1
• Reassess K+ within 1 week after treating acute hyperkalemia 1

Common Pitfalls to Avoid

1. Pseudohyperkalemia: Rule out hemolysis, poor phlebotomy technique, repeated fist clenching before treating 1

2. Hypoglycemia from insulin: Particularly dangerous in non-diabetics—monitor glucose closely 2

3. Using SPS: High risk of GI complications with questionable efficacy 1, 2

4. Stopping RAAS inhibitors: Increases mortality; treat hyperkalemia instead 4, 1

5. Ignoring clinical context: Focus on ECG changes and clinical impact, not just arbitrary K+ thresholds 1