From the Guidelines
Hyperkalemia is considered clinically significant when serum potassium levels exceed 5.5 mEq/L, with severe hyperkalemia defined as levels above 6.0 mEq/L requiring immediate intervention, as stated in the most recent and highest quality study 1.
Definition and Severity of Hyperkalemia
The severity of hyperkalemia can be classified as mild (>5.0 to <5.5 mEq/L), moderate (5.5 to 6.0 mEq/L), and severe at thresholds (>6.0 mEq/L) 1.
- Mild hyperkalemia: >5.0 to <5.5 mEq/L
- Moderate hyperkalemia: 5.5 to 6.0 mEq/L
- Severe hyperkalemia: >6.0 mEq/L
Treatment Options
Treatment options depend on the severity and presence of ECG changes.
- For mild to moderate hyperkalemia (5.5-6.0 mEq/L) without ECG changes, options include:
- Potassium-binding resins like sodium polystyrene sulfonate (Kayexalate) 15-30g orally or rectally
- Newer agents like patiromer (Veltassa) 8.4g daily or sodium zirconium cyclosilicate (Lokelma) 10g three times daily
- Loop diuretics such as furosemide 20-40mg IV to enhance potassium excretion in patients with adequate kidney function
- For severe hyperkalemia (>6.0 mEq/L) or when ECG changes are present, immediate stabilization of cardiac membranes with calcium gluconate 10% solution (10mL IV over 2-3 minutes) is necessary, followed by shifting potassium intracellularly using insulin (10 units regular insulin IV with 25g dextrose) or albuterol nebulizer (10-20mg) 1.
Underlying Cause and Contributing Medications
The underlying cause of hyperkalemia should always be addressed, including discontinuation of contributing medications such as ACE inhibitors, ARBs, potassium-sparing diuretics, and NSAIDs 1.
- Contributing medications:
- ACE inhibitors
- ARBs
- Potassium-sparing diuretics
- NSAIDs
Importance of Rapid Intervention
Hyperkalemia is dangerous because elevated extracellular potassium disrupts the normal membrane potential of cardiac cells, leading to arrhythmias and potentially cardiac arrest, which explains why rapid intervention is crucial in severe cases 1.
From the FDA Drug Label
Sodium polystyrene sulfonate is a potassium binder indicated for the treatment of hyperkalemia The FDA drug label does not answer the question.
From the Research
Definition and Significance of Hyperkalemia
- Hyperkalemia is defined as a condition where a serum potassium level is >5.5 mmol/l 2 or >5.0 mmol/L 3, and it is associated with fatal dysrhythmias and muscular dysfunction.
- The presence of typical electrocardiographic changes or a rapid rise in serum potassium indicates that hyperkalemia is potentially life threatening 4.
Treatment Options for Hyperkalemia
- Treatment includes measures to "stabilize" cardiac membranes, to shift K+ from extracellular to intracellular stores, and to promote K+ excretion 5.
- 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 5.
- Beta-agonists and intravenous insulin should be given, and some experts recommend the use of synthetic short-acting insulins rather than regular insulin 5.
- Dialysis is the most efficient means to enable removal of excess K+ 5.
- Loop and thiazide diuretics can also be useful 5.
- New medications to promote gastrointestinal K+ excretion, which include patiromer and sodium zirconium cyclosilicate, hold promise 5, 2.
Management of Hyperkalemia
- A history and physical examination can be beneficial in the diagnosis of the condition 2.
- Certain characteristic electrocardiogram findings are associated with hyperkalemia along with laboratory potassium levels 2, 4.
- Urine potassium, creatinine, and osmolarity should be obtained as a first step in determining the cause of hyperkalemia, which directs long-term treatment 4.
- Sodium polystyrene sulfonate is not efficacious 5, but it can be used in non-acute situations 6.