What is the management of hyperkalemia?

From the Guidelines

The management of hyperkalemia involves a stepwise approach based on severity and symptoms, with the most recent and highest quality study suggesting that for mild hyperkalemia, dietary potassium restriction and discontinuation of potassium-sparing medications is often sufficient, while for moderate to severe hyperkalemia, immediate treatment with calcium gluconate, insulin, and beta-agonists is necessary 1.

Key Considerations

• The severity of hyperkalemia and the presence of ECG changes guide the treatment approach.
• For mild hyperkalemia (5.5-6.0 mEq/L), dietary potassium restriction and discontinuation of potassium-sparing medications like ACE inhibitors, ARBs, and potassium supplements is often sufficient.
• For moderate to severe hyperkalemia (>6.0 mEq/L) or when ECG changes are present, immediate treatment is necessary, including:
  • Calcium gluconate (10%, 10-20 mL IV over 2-3 minutes) to stabilize cardiac membranes when ECG changes are present.
  • Insulin (10 units regular insulin IV) with glucose (25-50g IV) to drive potassium into cells within 15-30 minutes, lasting 4-6 hours.
  • Nebulized albuterol (10-20 mg) to promote intracellular potassium shift.
  • Sodium bicarbonate (50 mEq IV over 5 minutes) may help in acidotic patients.

Potassium Removal

• Loop diuretics like furosemide (40-80 mg IV) can increase renal excretion in patients with adequate kidney function.
• Sodium polystyrene sulfonate (15-30g orally or rectally) or newer potassium binders like patiromer (8.4-16.8g orally daily) or sodium zirconium cyclosilicate (10g orally three times daily) bind potassium in the gut.

Severe or Refractory Hyperkalemia

• Hemodialysis remains the most effective method for severe or refractory hyperkalemia, especially in patients with kidney failure.
• Continuous cardiac monitoring is essential during treatment, and serial potassium measurements should guide therapy adjustments.
• The underlying cause of hyperkalemia should be identified and addressed to prevent recurrence, as suggested by the most recent study 1.

From the FDA Drug Label

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. Therefore, other definitive measures, including dialysis, should always be considered and may be imperative.

The management of hyperkalemia may include the use of Sodium Polystyrene Sulfonate, USP, but this treatment alone may not be sufficient to rapidly correct severe hyperkalemia. Definitive measures, such as dialysis, should be considered and may be necessary in severe cases. The intensity and duration of therapy depend on the severity and resistance of hyperkalemia 2.

• Key considerations for the management of hyperkalemia include:
  • Monitoring serum potassium levels
  • Assessing the patient's clinical condition and electrocardiogram
  • Avoiding the use of sorbitol with Sodium Polystyrene Sulfonate, USP
  • Considering alternative therapies, such as dialysis, in severe cases 2

From the Research

Management of Hyperkalemia

The management of hyperkalemia involves several strategies to stabilize cardiac membranes, shift potassium from extracellular to intracellular stores, and promote potassium excretion.

• Treatment includes measures to stabilize cardiac membranes, such as administering calcium gluconate 10% dosed 10 mL intravenously 3.
• Beta-agonists and intravenous insulin should be given, with some experts recommending the use of synthetic short-acting insulins rather than regular insulin 3.
• Dextrose should also be administered, as indicated by initial and serial serum glucose measurements 3.
• Dialysis is the most efficient means to enable removal of excess potassium 3, 4, 5.
• Loop and thiazide diuretics can also be useful in promoting potassium excretion 3, 5.

Pharmacotherapies for Hyperkalemia

Several pharmacotherapies are available for the management of hyperkalemia, including:

• Sodium polystyrene sulfonate, although its efficacy has been questioned 3, 6.
• Sodium zirconium cyclosilicate and patiromer, which are new medications that promote gastrointestinal potassium excretion and hold promise 3, 6.
• Insulin with glucose, beta(2)-agonist (albuterol), and NaHCO(3), which can cause a transcellular shift of potassium 4.
• Calcium salts, such as calcium gluconate, which can help stabilize cardiac membranes 3, 5.

Clinical Considerations

The management of hyperkalemia requires careful consideration of the underlying causes and pathophysiologic mechanisms, as well as the patient's medical history and current medications 4, 5.

• A history and physical examination can be beneficial in the diagnosis of hyperkalemia, along with laboratory potassium levels and electrocardiogram findings 6.
• Frequent reevaluation of potassium concentrations is recommended to assess treatment success and to monitor for recurrence of hyperkalemia 5.