What are the steps to lower hyperkalemia in an 85-year-old patient with a history of atrial fibrillation (AFib), congestive heart failure (CHF), and hypertension (HTN)?

From the Guidelines

To manage hyperkalemia in an 85-year-old patient with atrial fibrillation, congestive heart failure, and hypertension, I strongly recommend a stepwise approach that prioritizes immediate stabilization, adjustment of contributing medications, and dietary modifications, as outlined in the most recent guidelines 1.

Immediate Management

The first step involves reviewing and adjusting medications that may contribute to hyperkalemia, such as ACE inhibitors, ARBs, potassium-sparing diuretics, and potassium supplements, as these can increase potassium levels 1. For life-threatening hyperkalemia, immediate treatment with calcium carbonate and hyperosmolar sodium (if the individual has hyponatremia) is crucial to stabilize the myocardial cell membrane, followed by insulin with or without glucose and/or beta-adrenoceptor agonists like salbutamol, and sodium bicarbonate to temporarily transfer potassium into cells 1.

Medication Adjustment

Consider switching to loop diuretics like furosemide 20-40mg daily, which enhance potassium excretion, as recommended for patients with heart failure and congestion to alleviate symptoms and facilitate better AF management 1. It's also important to note that renin-angiotensin-aldosterone system inhibitors (RAASi) are crucial for the treatment of patients with cardiovascular diseases but can cause hyperkalemia; thus, their use should be carefully managed 1.

Dietary Modifications

Dietary modifications are essential, including limiting high-potassium foods such as bananas, oranges, potatoes, tomatoes, and salt substitutes, which can contribute to elevated potassium levels 1.

Potassium Lowering Agents

For moderate hyperkalemia, oral sodium polystyrene sulfonate (Kayexalate) 15-30g once or twice daily can be effective, but it's crucial to monitor renal function closely, as impaired kidney function commonly contributes to hyperkalemia in elderly patients with heart failure 1. Other potassium binders like patiromer sorbitex calcium (PSC) or sodium zirconium cyclosilicate (SZC) can also be considered for managing hyperkalemia 1.

Monitoring and Follow-Up

Repeat potassium measurements within 24-48 hours after interventions begin to assess the effectiveness of the treatment strategy and adjust as necessary. This approach addresses the patient's elevated potassium while considering their complex cardiac conditions, recognizing that hyperkalemia poses a particular risk in patients with atrial fibrillation by potentially worsening cardiac arrhythmias 1.

From the FDA Drug Label

In the open-label acute phase of Study 2,258 patients with hyperkalemia (baseline mean 5.6 mEq/L, range 5.1 to 7. 4 mEq/L) received 10 g of LOKELMA administered three times daily with meals for 48 hours. As shown in Figure 3, left, average serum potassium levels decreased from 5.6 to 4.5 mEq/L during treatment with LOKELMA in the acute phase.

The steps to lower hyperkalemia in an 85-year-old patient with a history of atrial fibrillation (AFib), congestive heart failure (CHF), and hypertension (HTN) are:

• Administer 10 g of LOKELMA three times daily with meals for 48 hours in the acute phase.
• Following the acute phase, patients who achieve potassium levels between 3.5 and 5 mEq/L can be randomized to one of three doses of LOKELMA (5,10, or 15 g) administered once-daily for 28 days.
• The dose of LOKELMA may need to be adjusted based on serum potassium levels. 2 2

From the Research

Lowering Hyperkalemia in an 85-year-old Patient

To lower hyperkalemia in an 85-year-old patient with a history of atrial fibrillation (AFib), congestive heart failure (CHF), and hypertension (HTN), the following steps can be considered:

• Monitoring serum potassium levels frequently, especially in the presence of renal impairment (RI) 3
• Reducing the dose of spironolactone to 12.5 mg daily if hyperkalemia occurs, as this can help normalize serum potassium levels 3
• Considering the use of other standard therapies for congestive heart failure, such as angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, and beta-blockers, which may also have a role in managing hyperkalemia 4, 5
• Managing atrial fibrillation, as it is a common coexisting condition with CHF and can worsen hyperkalemia, through the use of antiarrhythmic drugs or other treatments 6, 4, 5

Considerations for the Patient's Conditions

The patient's history of AFib, CHF, and HTN should be taken into account when managing hyperkalemia, as these conditions can affect the patient's response to treatment and increase the risk of complications.

• Atrial fibrillation is a common risk factor for hyperkalemia and should be managed accordingly 6, 4, 5
• Congestive heart failure can worsen hyperkalemia, and standard therapies for CHF may be beneficial in managing hyperkalemia 3, 4, 5
• Hypertension should be managed to reduce the risk of cardiovascular complications, including hyperkalemia 7