What is the management algorithm for hyperkalemia?

From the Guidelines

The management of hyperkalemia involves a stepwise approach based on severity and clinical presentation, with the most recent and highest quality study recommending a combination of stabilizing cardiac membranes, shifting potassium intracellularly, and removing excess potassium 1. For mild hyperkalemia (5.5-6.0 mEq/L) without ECG changes, the following steps can be taken:

• Discontinue potassium-containing medications and supplements
• Restrict dietary potassium
• Address underlying causes For moderate to severe hyperkalemia (>6.0 mEq/L) or any level with ECG changes, immediate intervention is required, including:
• Stabilizing cardiac membranes with IV calcium gluconate 10% (10 mL over 2-3 minutes, can be repeated after 5 minutes if ECG changes persist)
• Shifting potassium intracellularly using insulin (10 units regular insulin IV with 25g dextrose to prevent hypoglycemia), beta-2 agonists (albuterol 10-20 mg nebulized), and sodium bicarbonate (50 mEq IV over 5 minutes if metabolic acidosis is present)
• Removing excess potassium using sodium polystyrene sulfonate (15-30g orally or rectally), patiromer (8.4-25.2g orally daily), sodium zirconium cyclosilicate (10g orally three times daily), or loop diuretics if kidney function permits For severe or refractory cases, dialysis is the definitive treatment, as noted in the study published in the Mayo Clinic Proceedings 1. Continuous cardiac monitoring is essential throughout treatment, and these interventions work by either stabilizing cardiac cell membranes to prevent arrhythmias, temporarily shifting potassium into cells, or eliminating excess potassium from the body. It is also important to evaluate the patient's diet, use of supplements, salt substitutes, and nutraceuticals that contain K+, as well as concomitant medications that may contribute to hyperkalemia, as recommended by the European Heart Journal study 1. Additionally, kidney function must be determined and monitored, and a low-K+ diet and loop or thiazide diuretics that increase K+ excretion may be considered to reduce the occurrence of hyperkalemia, as suggested by the European Society of Cardiology study 1. The use of new K+ binders, such as patiromer and sodium zirconium cyclosilicate, may also be beneficial in managing hyperkalemia, as noted in the study published in the European Heart Journal 1. Overall, the management of hyperkalemia requires a comprehensive approach that takes into account the severity of the condition, underlying causes, and individual patient factors, with the goal of reducing morbidity, mortality, and improving quality of life.

From the FDA Drug Label

1. 1 Mechanism of Action Veltassa is a non-absorbed, cation exchange polymer that contains a calcium-sorbitol counterion. Veltassa increases fecal potassium excretion through binding of potassium in the lumen of the gastrointestinal tract. Binding of potassium reduces the concentration of free potassium in the gastrointestinal lumen, resulting in a reduction of serum potassium levels.

The management algorithm for hyperkalemia using Veltassa involves:

• Dose-dependent increase in fecal potassium excretion: Veltassa doses of 25.2 and 50.4 grams per day significantly decreased mean daily urinary potassium excretion 2.
• Reduction of serum potassium levels: A statistically significant reduction in serum potassium (-0.2 mEq/L) was observed at 7 hours after the first dose, and serum potassium levels continued to decline during the 48-hour treatment period (-0.8 mEq/L at 48 hours after the first dose) 2.
• Administration: Veltassa can be taken with or without food, and for oral drug products not listed in Table 3, administration of patiromer should be separated by at least 3 hours as a precautionary measure 2.
• Key considerations:
  • No special dosing adjustments are needed for patients with renal impairment 2.
  • Excessive doses of Veltassa may result in hypokalemia, and serum potassium should be restored if hypokalemia occurs 2.

From the Research

Hyperkalemia Management Algorithm

The management of hyperkalemia involves several key steps, including:

• Stabilization of cardiac membranes
• Shifting of potassium from extracellular to intracellular stores
• Promotion of potassium excretion
• Identification and treatment of underlying causes

Stabilization of Cardiac Membranes

This can be achieved through the administration of calcium gluconate 10% dosed 10 mL intravenously, unless the patient is in cardiac arrest, in which case 10 mL calcium chloride is warranted 3, 4, 5.

Shifting of Potassium

This can be achieved through the use of:

• Beta-agonists, such as albuterol 3, 6
• Intravenous insulin, with or without glucose 3, 4, 6, 5
• Sodium bicarbonate (NaHCO3), although its use is less favored due to poor efficacy 6

Promotion of Potassium Excretion

This can be achieved through:

• Dialysis, which is the most efficient means of removing excess potassium 3, 4, 6
• Loop and thiazide diuretics 3
• New medications, such as patiromer and sodium zirconium cyclosilicate, which promote gastrointestinal potassium excretion 3, 7

Identification and Treatment of Underlying Causes

It is essential to identify and treat the underlying causes of hyperkalemia, including:

• Renal potassium excretion problems 5
• Excess potassium intake 5
• Medications that inhibit the renin-angiotensin-aldosterone system 5

Treatment Approach

The treatment approach for hyperkalemia should be individualized based on the severity of the condition and the presence of ECG changes. For life-threatening hyperkalemia, immediate treatment with calcium salts, insulin, and glucose, and beta-agonists may be necessary 4, 5. In less severe cases, treatment may focus on promoting potassium excretion and addressing underlying causes. Novel oral potassium-binding agents, such as patiromer and sodium zirconium cyclosilicate, may also be considered 7.