What is the treatment for hyperkalemia caused by Angiotensin-Converting Enzyme (ACE) inhibitors and Angiotensin Receptor Blockers (ARBs)?

From the Guidelines

The treatment for hyperkalemia caused by ACE inhibitors or ARBs involves discontinuing or reducing the dose of the offending medication, along with measures to lower potassium levels, and considering the use of potassium binders such as patiromer or sodium zirconium cyclosilicate to enable patients to continue RAASi therapy. For mild hyperkalemia (5.0-5.9 mEq/L), dietary potassium restriction and loop diuretics like furosemide (20-40mg orally daily) may be sufficient 1. The following measures can be taken to manage hyperkalemia:

• Discontinuing or reducing the dose of the offending medication
• Dietary potassium restriction
• Loop diuretics like furosemide (20-40mg orally daily)
• Oral potassium binders such as sodium polystyrene sulfonate (15-30g orally 1-4 times daily) or patiromer (8.4-16.8g daily) for moderate hyperkalemia (6.0-6.4 mEq/L)
• Emergency treatment with IV calcium gluconate, insulin, and sodium bicarbonate for severe hyperkalemia (>6.5 mEq/L) 1. The use of potassium binders such as patiromer or sodium zirconium cyclosilicate can help to lower potassium levels and enable patients to continue RAASi therapy, which is essential for reducing mortality and morbidity in patients with cardiovascular disease 1. In patients with hyperkalemia, it is essential 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, and to closely monitor K+ levels to protect against development of hypokalaemia 1. The treatment approach should be individualized based on the severity of hyperkalemia, the patient’s clinical status, and the presence of other comorbidities, with the goal of minimizing morbidity, mortality, and improving quality of life 1.

From the FDA Drug Label

In Part A, 243 patients were treated with Veltassa for 4 weeks. Patients with a baseline serum potassium of 5.1 mEq/L to < 5.5 mEq/L received a starting Veltassa dose of 8.4 grams patiromer per day (as a divided dose) and patients with a baseline serum potassium of 5.5 mEq/L to < 6.5 mEq/L received a starting Veltassa dose of 16.8 grams patiromer per day (as a divided dose). The dose of Veltassa was titrated, as needed, based on the serum potassium level, assessed starting on Day 3 and then at weekly visits (Weeks 1,2 and 3) to the end of the 4-week treatment period, with the aim of maintaining serum potassium in the target range (3.8 mEq/L to < 5.1 mEq/L).

The treatment for hyperkalemia caused by Angiotensin-Converting Enzyme (ACE) inhibitors and Angiotensin Receptor Blockers (ARBs) is Veltassa (patiromer). The starting dose is:

• 8.4 grams per day for patients with a baseline serum potassium of 5.1 mEq/L to < 5.5 mEq/L
• 16.8 grams per day for patients with a baseline serum potassium of 5.5 mEq/L to < 6.5 mEq/L The dose is titrated as needed to maintain serum potassium in the target range of 3.8 mEq/L to < 5.1 mEq/L 2.

From the Research

Treatment of Hyperkalemia Caused by ACE Inhibitors and ARBs

The treatment of hyperkalemia caused by Angiotensin-Converting Enzyme (ACE) inhibitors and Angiotensin Receptor Blockers (ARBs) involves several steps:

• Prompt recognition of cardiac dysrhythmias and effective treatment to antagonize the cardiac effects of potassium 3
• Redistribution of potassium into cells 3
• Removal of excess potassium from the body 3
• Discontinuation of the offending agent (ACE inhibitor or ARB) if necessary 4
• Use of gastrointestinal potassium binding agents such as patiromer to increase kaliuresis and lower serum potassium levels 5
• Hemodialysis in severe cases 6

Risk Factors for Hyperkalemia

Several risk factors for hyperkalemia have been identified, including:

• Chronic renal insufficiency 3, 7, 4
• Congestive heart failure 7
• Excessive potassium intake from diet, supplements, or drugs 3
• Use of loop or thiazide diuretic agents, which can increase the risk of hyperkalemia 7
• Age over 70 years 7
• Serum urea nitrogen level higher than 6.4 mmol/L (18 mg/dL) or creatinine level higher than 136 mumol/L (1.5 mg/dL) 7

Monitoring and Prevention

To prevent hyperkalemia, it is essential to:

• Obtain an estimate of glomerular filtration rate and a baseline serum potassium concentration before initiating ACE inhibitor or ARB therapy 3
• Monitor serum potassium levels shortly after initiation of therapy 3
• Assess whether the patient has excessive potassium intake from diet, supplements, or drugs 3
• Use judicious drug use and clinical vigilance to minimize the risk of developing hyperkalemia 3