From the Guidelines
The treatment of hyperkalemia should prioritize the administration of calcium gluconate to stabilize cardiac membranes, followed by insulin and glucose to drive potassium into cells, and then the use of potassium-lowering agents such as sodium polystyrene sulfonate, patiromer, or sodium zirconium cyclosilicate to remove excess potassium from the body, as recommended by the most recent and highest quality study 1.
Treatment Approach
The approach to treating hyperkalemia depends on the severity of the condition and the presence of symptoms or ECG changes. For mild cases, dietary restrictions and discontinuation of potassium-increasing medications may suffice. However, for moderate to severe hyperkalemia or when ECG changes are present, more aggressive interventions are necessary.
Initial Stabilization
- Calcium gluconate: Administered first to stabilize cardiac membranes if ECG changes are present, it does not lower potassium levels but protects the heart while other treatments take effect 1.
- Insulin with glucose: Drives potassium into cells temporarily, with effects lasting 4-6 hours 1.
- Inhaled beta-2 agonists: Like albuterol, can also shift potassium intracellularly 1.
Potassium Removal
- Sodium polystyrene sulfonate: Can be used orally or rectally to remove potassium from the body 1.
- Patiromer: Or sodium zirconium cyclosilicate can be used for definitive removal of potassium 1.
- Loop diuretics: Like furosemide, enhance renal potassium excretion in patients with adequate kidney function 1.
- Hemodialysis: Remains the most effective method for potassium removal in severe cases or renal failure 1.
Monitoring and Adjustment
Continuous cardiac monitoring is essential during treatment, and serial potassium measurements should guide therapy adjustments 1. The goal is to prevent morbidity, mortality, and to improve the quality of life for patients with hyperkalemia.
Considerations
It's crucial to consider the patient's overall clinical context, including the presence of cardiovascular disease, kidney function, and the use of medications that may affect potassium levels, such as renin-angiotensin-aldosterone system inhibitors 1. Regular monitoring of potassium levels and adjustment of treatment as necessary is vital to prevent the complications of hyperkalemia 1.
From the FDA Drug Label
Sodium Polystyrene Sulfonate Powder, for Suspension is indicated for the treatment of hyperkalemia. 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. The intensity and duration of therapy depend upon the severity and resistance of hyperkalemia.
The treatment recommendations for hyperkalemia (elevated potassium levels) include administering Sodium Polystyrene Sulfonate Powder, for Suspension at a dose of 15 g to 60 g per day, given in divided doses of 15 g (four level teaspoons) one to four times daily. The intensity and duration of therapy should be based on the severity and resistance of hyperkalemia 2.
- Key considerations:
- Administer the suspension at least 3 hours before or 3 hours after other oral medications.
- Prepare the suspension fresh and use within 24 hours.
- Monitor serum potassium during therapy, as well as calcium and magnesium levels.
- Avoid use in patients with obstructive bowel disease, hypersensitivity to polystyrene sulfonate resins, or neonates with reduced gut motility.
From the Research
Treatment Recommendations for Hyperkalemia
The treatment of hyperkalemia involves several strategies, including measures to stabilize cardiac membranes, shift potassium from extracellular to intracellular stores, and promote potassium excretion 3, 4.
- Membrane Stabilization: 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.
- Cellular Shift: Beta-agonists and intravenous insulin should be given to shift potassium into cells 3, 5. Dextrose should also be administered, as indicated by initial and serial serum glucose measurements 3.
- Potassium Excretion: Dialysis is the most efficient means to enable removal of excess potassium 3, 4. Loop and thiazide diuretics can also be useful 3.
- New Medications: New medications to promote gastrointestinal potassium excretion, which include patiromer and sodium zirconium cyclosilicate, hold promise 3, 6.
- Treatment Approach: The choice of treatment approach depends on the severity of hyperkalemia and the presence of cardiac arrhythmias or other complications 4. Hyperkalemia with potassium level more than 6.5 mEq/L or EKG changes is a medical emergency and should be treated accordingly 4.
Specific Treatment Strategies
Specific treatment strategies for hyperkalemia include:
- Intravenous Insulin with Glucose: Effective in lowering plasma potassium levels 5, 7.
- Nebulized Albuterol: Also effective in lowering plasma potassium levels 5.
- Combined Regimen: A combined regimen of insulin, glucose, and albuterol is efficacious and safe for the acute treatment of hyperkalemia in hemodialysis patients 5.
- Hemodialysis: The most reliable method to remove potassium from the body and should be used in cases refractory to medical treatment 4, 7.