What is the treatment for hyperkalemia?

From the Guidelines

The treatment for hyperkalemia involves several approaches depending on severity, and the most recent and highest quality study recommends a combination of calcium gluconate, insulin with glucose, and potassium binders for acute management. For mild hyperkalemia (potassium 5.5-6.0 mEq/L), dietary potassium restriction and discontinuation of medications that increase potassium levels (like ACE inhibitors, ARBs, and potassium-sparing diuretics) may be sufficient 1. For moderate to severe hyperkalemia (potassium >6.0 mEq/L), more urgent interventions are needed, including:

• Calcium gluconate (1 ampule of 10% solution IV over 2-3 minutes) to stabilize cardiac membranes and prevent arrhythmias
• Insulin with glucose (10 units regular insulin with 25g dextrose IV) to drive potassium into cells temporarily, lowering serum levels within 15-30 minutes
• Inhaled beta-2 agonists like albuterol (10-20 mg nebulized) to shift potassium intracellularly
• Sodium bicarbonate (50 mEq IV over 5 minutes) to help in acidotic patients
• Potassium binders such as patiromer (8.4-25.2g daily) or sodium zirconium cyclosilicate (10g three times daily initially) for definitive removal of potassium
• Loop diuretics like furosemide (40-80mg IV) to enhance renal potassium excretion in patients with adequate kidney function
• Hemodialysis in severe cases or renal failure, which remains the most effective method for potassium removal 1.

Key considerations in the management of hyperkalemia include:

• Individualized monitoring of serum potassium levels based on patient comorbidities and medications
• Optimization of renin-angiotensin-aldosterone system inhibitor (RAASi) therapy
• Use of newer potassium binders to enable the optimization of RAASi therapy in more patients with hyperkalemia
• Long-term potassium-binding therapy for patients with chronic hyperkalemia, initiated at the recommended dose and titrated according to serum potassium levels 1.

Overall, the management of hyperkalemia requires a comprehensive approach that takes into account the severity of the condition, the underlying cause, and the patient's individual needs and comorbidities.

From the FDA Drug Label

Sodium polystyrene sulfonate is indicated for the treatment of hyperkalemia. Sodium Polystyrene Sulfonate, USP is indicated for the treatment of hyperkalemia. Alternative Therapy in Severe Hyperkalemia Since effective lowering of serum potassium with Sodium Polystyrene Sulfonate, USP may take hours to days, treatment with this drug alone may be insufficient to rapidly correct severe hyperkalemia associated with states of rapid tissue breakdown (e.g., burns and renal failure) or hyperkalemia so marked as to constitute a medical emergency.

The treatment for hyperkalemia includes sodium polystyrene sulfonate. However, for severe hyperkalemia, other definitive measures, including dialysis, should always be considered and may be imperative 2, 3, 3.

From the Research

Treatment of Hyperkalemia

The treatment of hyperkalemia involves a multifaceted approach, guided by potassium levels and clinical presentation 4, 5, 6, 7. The primary goals of treatment are to:

• Stabilize cell membrane potential
• Promote transcellular potassium shift
• Lower total potassium body content

Emergency Treatment

In cases of severe hyperkalemia (potassium level > 6.5 mEq/L or EKG changes), treatment should be started with:

• Calcium gluconate to stabilize cardiomyocyte membranes 4, 8, 6
• Insulin injection and beta-2 agonists administration to promote transcellular potassium shift 4, 5, 6
• Hemodialysis remains the most reliable method to remove potassium from the body and should be used in cases refractory to medical treatment 4, 6

Non-Emergency Treatment

For non-emergency cases, treatment may include:

• Elimination of reversible causes (diet, medications) 4, 6
• Oral binding resins, such as sodium polystyrene sulfonate, patiromer, and sodium zirconium cyclosilicate, to increase gastrointestinal potassium elimination 5, 7
• Saline diuresis to increase potassium elimination by urine 4, 6

New Treatment Options

New drugs, such as patiromer and sodium zirconium cyclosilicate, have been developed to treat hyperkalemia by increasing gastrointestinal potassium elimination 5, 7. These medications have proved their efficacy and safety in large clinical trials, involving subjects at high risk of hyperkalemia, such as patients with heart failure and chronic kidney disease.

Key Considerations

• Prompt detection and proper treatment are crucial in preventing lethal outcomes 4
• Clinicians must be aware of the unique benefits and contraindications of each medication when managing patients with hyperkalemia 5
• A long-term plan to prevent recurrence or worsening of hyperkalemia is essential, including elucidating underlying causes and pathophysiologic mechanisms, and uncovering overt or covert medications that may have led to the development of hyperkalemia 6