What is the management of hyperkalemia caused by medications such as Angiotensin-Converting Enzyme (ACE) inhibitors, Angiotensin Receptor Blockers (ARBs), and potassium-sparing diuretics?

From the Guidelines

The management of hyperkalemia caused by medications such as Angiotensin-Converting Enzyme (ACE) inhibitors, Angiotensin Receptor Blockers (ARBs), and potassium-sparing diuretics primarily involves discontinuing the offending drug and implementing measures to lower potassium levels, as recommended by the European Society of Cardiology in 2018 1. When ACE inhibitors, ARBs, or potassium-sparing diuretics cause hyperkalemia, the first step is to hold or discontinue these medications, especially if potassium levels exceed 5.5 mEq/L.

Key Considerations

• For mild hyperkalemia (5.5-6.0 mEq/L), dietary potassium restriction and switching to alternative medications like calcium channel blockers or thiazide diuretics may be sufficient.
• For moderate hyperkalemia (6.0-6.5 mEq/L), oral potassium binders such as sodium polystyrene sulfonate (Kayexalate) 15-30g or patiromer 8.4g daily can be used, as suggested by the expert consensus document on the management of hyperkalaemia in patients with cardiovascular disease treated with renin angiotensin aldosterone system inhibitors 1.
• Severe hyperkalemia (>6.5 mEq/L) requires immediate intervention with IV calcium gluconate 10% solution (10mL over 2-3 minutes) to stabilize cardiac membranes, followed by insulin (10 units regular insulin IV with 25g dextrose) to shift potassium intracellularly, and sodium bicarbonate 50mEq IV if acidosis is present.

Additional Interventions

• Loop diuretics like furosemide 40-80mg IV can enhance potassium excretion.
• Hemodialysis may be necessary for life-threatening hyperkalemia or in patients with renal failure. After stabilization, addressing underlying causes, monitoring renal function, and careful medication reconciliation are essential to prevent recurrence, as highlighted in the standards of medical care in diabetes-2019 1. These interventions work by either shifting potassium into cells temporarily, increasing excretion, or binding potassium in the gastrointestinal tract to prevent absorption. It is also important to note that the combined use of ACE inhibitors and ARBs should be avoided due to the increased risk of hyperkalemia and/or acute kidney injury, as stated in the 2019 standards of medical care in diabetes 1.

From the Research

Medication-Induced Hyperkalemia

• Hyperkalemia is a common clinical condition characterized by a serum potassium concentration exceeding 5.0 mmol/L, and it can be caused by various medications, including Angiotensin-Converting Enzyme (ACE) inhibitors, Angiotensin Receptor Blockers (ARBs), and potassium-sparing diuretics 2, 3.
• These medications can interfere with potassium homeostasis by promoting transcellular potassium shift or by impairing renal potassium excretion, leading to increased potassium levels in the body 2.

Management of Medication-Induced Hyperkalemia

• The management of hyperkalemia caused by medications such as ACE inhibitors, ARBs, and potassium-sparing diuretics involves identifying patients prone to develop serious hyperkalemia and evaluating the associated morbidity and mortality 4.
• A combination of ACE inhibitors and spironolactone should be considered with caution and monitored closely in patients with renal insufficiency, diabetes, older age, worsening heart failure, a risk for dehydration, and in combination with other medications that may cause hyperkalemia 4.
• The toxic effects of hyperkalemia on the cardiac conduction system are potentially lethal, and the ECG is a mainstay in managing hyperkalemia 5.
• Membrane stabilization by calcium salts and potassium-shifting agents, such as insulin and salbutamol, is the cornerstone in the acute management of hyperkalemia, while dialysis, potassium-binding agents, and loop diuretics remove potassium from the body 5.

Risk Factors for Hyperkalemia

• Decreased renal function, expressed as estimated glomerular filtration rate (eGFR) <50 ml/min, is a significant risk factor for hyperkalemia in patients using potassium-influencing drugs, including ACE inhibitors, ARBs, and potassium-sparing diuretics 6.
• Other risk factors, such as diabetes mellitus, congestive heart failure, advanced age, and use of certain medications, may also contribute to the development of hyperkalemia, but decreased renal function is the most significant risk factor 6.