From the Guidelines
Hypokalemia is primarily caused by excessive potassium loss through the kidneys or gastrointestinal tract, with common causes including diuretic medications, vomiting, diarrhea, and laxative abuse, as well as certain medications and endocrine disorders. The causes of hypokalemia can be categorized into several key areas, including:
- Excessive potassium loss through the kidneys, often due to diuretic medications (especially thiazides and loop diuretics like furosemide) 1
- Gastrointestinal loss, such as vomiting, diarrhea, and laxative abuse
- Certain medications, including high-dose penicillins, amphotericin B, and steroids, which can promote potassium excretion
- Endocrine disorders, particularly primary hyperaldosteronism, Cushing's syndrome, and diabetic ketoacidosis
- Inadequate dietary intake, which rarely causes hypokalemia alone but can worsen existing deficiencies
- Alkalosis (high blood pH), which shifts potassium into cells, lowering serum levels
- Other causes, including renal tubular acidosis, magnesium deficiency, excessive sweating, and genetic disorders like Bartter and Gitelman syndromes
- Certain conditions that increase cellular potassium uptake, such as insulin administration, beta-adrenergic stimulation, and periodic paralysis It's worth noting that the most recent and highest quality study on this topic is from 2018 1, which highlights the importance of considering the underlying cause of hypokalemia and addressing it while replenishing potassium stores through oral or intravenous supplementation. Additionally, the study emphasizes the need to monitor serum potassium levels closely, especially in patients with cardiovascular disease treated with renin-angiotensin-aldosterone system inhibitors.
From the FDA Drug Label
Hypokalemia may develop with Furosemide tablets, especially with brisk diuresis, inadequate oral electrolyte intake, when cirrhosis is present, or during concomitant use of corticosteroids, ACTH, licorice in large amounts, or prolonged use of laxatives. Hypokalemia may develop, especially with brisk diuresis when severe cirrhosis is present, during concomitant use of corticosteroid or adrenocorticotropic hormone (ACTH) or after prolonged therapy. Insulin stimulates potassium movement into the cells, possibly leading to hypokalemia, that left untreated may cause respiratory paralysis, ventricular arrhythmia, and death.
The causes of hypokalemia include:
- Brisk diuresis
- Inadequate oral electrolyte intake
- Presence of cirrhosis
- Concomitant use of:
- Corticosteroids
- Adrenocorticotropic hormone (ACTH)
- Licorice in large amounts
- Prolonged use of laxatives
- Insulin therapy, which stimulates potassium movement into cells 2, 3, 4
From the Research
Causes of Hypokalemia
The causes of hypokalemia can be categorized into several factors, including:
- Potassium deficiency due to inadequate intake or excessive loss
- Net potassium shifts from the extracellular to the intracellular compartment
- Renal or extrarenal losses
- Use of certain medications, such as diuretics
- Abnormalities of the pituitary-adrenal axis
- Renal disorders, including tumors
- Gastrointestinal potassium wasting
Specific Causes
Some specific causes of hypokalemia include:
- Diuretic use, particularly loop diuretics and thiazides 5, 6, 7
- Gastrointestinal losses, such as those caused by biliary tract or bowel disorders 6
- Inappropriate potassium wasting, as indicated by a urinary potassium excretion of 20 mEq or more per day in the presence of a low serum potassium 6
- Abnormalities of the pituitary-adrenal axis 6
- Renal disorders, including tumors 6
- Medications, such as those that increase the risk of potassium depletion or cardiac arrhythmias 7
Diagnosis and Treatment
Diagnosis of hypokalemia is based on the level of serum potassium, and treatment aims to replace potassium intravenously or orally, or prevent further potassium loss 5, 6, 8, 9. The speed and extent of potassium replacement should be dictated by the clinical picture and guided by frequent reassessment of serum potassium concentration 9. Reducing diuretic dose and potassium supplementation are the most direct and effective therapies for hypokalemia 7.