How to manage hyperkalemia?

From the Guidelines

Managing hyperkalemia requires prompt intervention based on severity, and the most recent evidence suggests starting with calcium gluconate 10% (10 mL IV over 2-3 minutes) to stabilize cardiac membranes if ECG changes are present, as recommended by the 2021 study in Mayo Clinic Proceedings 1. For mild hyperkalemia (5.5-6.0 mEq/L), dietary potassium restriction and discontinuation of potassium-sparing medications may suffice. Some key points to consider in managing hyperkalemia include:

• Discontinuation of medications that may cause hyperkalemia, such as potassium-sparing diuretics, beta-blockers, and NSAIDs, as listed in the 2018 expert consensus document in the European Heart Journal 1.
• Dietary potassium restriction, with a suggested intake of less than 2,000 to 3,000 mg (50 to 75 mmol/d) of K daily, as recommended by the 2009 KDOQI clinical practice guideline in the American Journal of Kidney Diseases 1.
• For moderate to severe hyperkalemia (>6.0 mEq/L), immediate treatment is necessary, and may include:
  • Insulin (10 units regular insulin IV with 25g dextrose) and nebulized albuterol (10-20 mg) to shift potassium intracellularly.
  • Sodium polystyrene sulfonate (15-30g orally or rectally), or newer potassium binders like patiromer (8.4-25.2g daily) or sodium zirconium cyclosilicate (10g TID initially, then 5-15g daily) to remove excess potassium.
  • Loop diuretics like furosemide (40-80mg IV) to enhance potassium excretion in patients with adequate kidney function.
  • Hemodialysis is reserved for life-threatening hyperkalemia or when other measures fail, as recommended by the 2018 expert consensus document in the European Heart Journal 1. It is essential to monitor potassium levels, cardiac status, and address the underlying cause of hyperkalemia for comprehensive management, as emphasized by the 2021 study in Mayo Clinic Proceedings 1.

From the FDA Drug Label

INDICATION AND USAGE SPS® Suspension is indicated for the treatment of hyperkalemia. Alternative Therapy in Severe Hyperkalemia Since the effective lowering of serum potassium with sodium polystyrene sulfonate 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.

To manage hyperkalemia, sodium polystyrene sulfonate can be used. However, in cases of severe hyperkalemia, additional measures such as dialysis should be considered. The treatment should be carefully controlled by frequent serum potassium determinations within each 24 hour period to avoid hypokalemia.

• Monitor for electrolyte disturbances and systemic alkalosis.
• Administer other oral medications at least 3 hours before or 3 hours after sodium polystyrene sulfonate suspension.
• Patients with gastroparesis may require a 6 hour separation. 2 2

From the Research

Managing Hyperkalemia

To manage hyperkalemia, several strategies can be employed:

• Stabilize cardiac membranes: 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 3.
• Shift potassium from extracellular to intracellular stores: Beta-agonists and intravenous insulin should be given, and some experts recommend the use of synthetic short-acting insulins rather than regular insulin 3.
• Promote potassium excretion: Dialysis is the most efficient means to enable removal of excess K+ 3. Loop and thiazide diuretics can also be useful 3.
• New medications: New medications to promote gastrointestinal K+ excretion, which include patiromer and sodium zirconium cyclosilicate, hold promise 3, 4.

Treatment Approaches

Different treatment approaches can be considered:

• Intravenous calcium: Intravenous calcium is effective in reversing electrocardiographic changes and reducing the risk of arrhythmias but does not lower serum potassium 5, 6, 7.
• Intravenous insulin and glucose: Serum potassium levels can be lowered acutely by using intravenous insulin and glucose 5, 6, 7.
• Nebulized beta2 agonists: Nebulized beta2 agonists can also be used to lower serum potassium levels acutely 5, 6.
• Sodium polystyrene sulfonate: Sodium polystyrene sulfonate is not efficacious for acute treatment 3 but can be used for subacute treatment 5.

Prevention

Prevention of hyperkalemia currently rests largely upon:

• Dietary compliance: Avoiding high-potassium foods 6.
• Avoidance of medications: Avoiding medications that may promote hyperkalemia 6.
• Administration of intravenous dextrose: Prolonged fasting may provoke hyperkalemia, which can be prevented by administration of intravenous dextrose 6.