What is the initial management of hyperkalemia?

From the Guidelines

The initial management of hyperkalemia involves stabilizing cardiac membranes with intravenous calcium (calcium gluconate 10% 10-30 mL or calcium chloride 10% 5-10 mL over 2-5 minutes), followed by shifting potassium into cells using insulin (10 units regular insulin IV with 25-50g dextrose to prevent hypoglycemia), and beta-2 agonists (albuterol 10-20 mg nebulized) as recommended by the most recent study 1. These measures work quickly but temporarily. For definitive treatment, remove excess potassium from the body using sodium polystyrene sulfonate (15-30g orally or rectally), patiromer (8.4-25.2g orally), or sodium zirconium cyclosilicate (10g orally three times daily) as outlined in the study 1. Loop diuretics like furosemide (40-80mg IV) can enhance potassium excretion in patients with adequate kidney function. Hemodialysis should be considered for severe hyperkalemia (>6.5 mEq/L), especially with ECG changes, acute kidney injury, or when other measures fail. These interventions work through different mechanisms:

• calcium antagonizes cardiac effects without changing potassium levels,
• insulin drives potassium into cells by activating Na-K-ATPase pumps,
• and binding resins exchange potassium for sodium or calcium in the intestine for elimination. Key considerations in managing hyperkalemia include monitoring serum potassium levels, especially in patients with chronic kidney disease, diabetes, heart failure, or a history of hyperkalemia, and those receiving renin-angiotensin-aldosterone system inhibitor (RAASi) therapy as noted in the study 1. The use of newer K+-binding agents like patiromer and sodium zirconium cyclosilicate may facilitate optimization of RAASi therapy and more effective management of hyperkalemia as suggested by the study 1. It is also important to be aware of the potential causes of hyperkalemia, including certain medications and substances, as listed in the study 1. Overall, the management of hyperkalemia requires a comprehensive approach that takes into account the underlying cause, the severity of the condition, and the individual patient's needs.

From the FDA Drug Label

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

The initial management of hyperkalemia may require definitive measures such as dialysis, especially in severe cases. Sodium polystyrene sulfonate can be used to treat hyperkalemia, but its effect may take hours to days and may be insufficient to rapidly correct severe hyperkalemia.

• Dialysis should be considered in severe cases.
• Frequent serum potassium determinations are necessary to monitor the effect of treatment.
• The treatment should be individualized based on the patient's clinical condition and electrocardiogram 2.

From the Research

Initial Management of Hyperkalemia

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

• Stabilization of cardiac membranes is typically achieved with calcium gluconate 10% dosed 10 mL intravenously, unless the patient is in cardiac arrest, in which case 10 mL calcium chloride is warranted 3, 4, 5.
• Shifting potassium from extracellular to intracellular stores can be accomplished with beta-agonists and intravenous insulin, with some experts recommending the use of synthetic short-acting insulins rather than regular insulin 3, 4, 5.
• Promoting potassium excretion can be achieved through dialysis, which is the most efficient means of removing excess potassium, as well as loop and thiazide diuretics 3, 4, 6.

Treatment Strategies

Treatment strategies for hyperkalemia may vary depending on the severity of the condition and the presence of electrocardiogram (ECG) changes.

• For severe hyperkalemia with ECG changes, treatment should be started with calcium gluconate to stabilize cardiomyocyte membranes, followed by insulin injection and beta-agonists administration 4, 5.
• Hemodialysis remains the most reliable method to remove potassium from the body and should be used in cases refractory to medical treatment 3, 4, 6.
• New medications, such as patiromer and sodium zirconium cyclosilicate, which promote gastrointestinal potassium excretion, hold promise for the management of hyperkalemia 3, 7.

Prevention and Patient Safety

Prevention of hyperkalemia is crucial, particularly in patients with chronic kidney disease or those taking medications that may affect potassium homeostasis.

• Dietary compliance and avoidance of medications that may promote hyperkalemia are essential in preventing hyperkalemia 6.
• Changes to prescribing systems and an agreed institutional protocol for management of hyperkalemia can improve patient safety for this frequently encountered electrolyte disorder 5.