What is the treatment for hyperkalemia?

Treatment of Hyperkalemia

The treatment of hyperkalemia requires a stratified approach based on severity, with life-threatening hyperkalemia demanding immediate intervention using calcium to stabilize cardiac membranes, followed by insulin with glucose and beta-agonists to shift potassium intracellularly, while definitive treatment focuses on potassium elimination through diuretics, potassium binders, or dialysis. 1

Classification and Assessment

Hyperkalemia is classified as:

• Mild: K+ 5.0-5.9 mEq/L
• Moderate: K+ 6.0-6.4 mEq/L
• Severe: K+ ≥6.5 mEq/L

Priority assessment should include:

• ECG changes (peaked T waves, widened QRS, prolonged PR interval)
• Symptoms (muscle weakness, paresthesias, cardiac arrhythmias)
• Rate of potassium rise (acute vs chronic)
• Underlying conditions (heart failure, kidney disease)

Acute Management Algorithm

1. Severe or Symptomatic Hyperkalemia (K+ ≥6.5 mEq/L or ECG changes)

Cardiac Membrane Stabilization:

• Calcium chloride or calcium gluconate IV (10 ml of 10% solution) 1
• Onset: 1-3 minutes; Duration: 30-60 minutes
• May repeat if ECG changes persist

Intracellular Shift of Potassium:

• Insulin 10 units IV with 50 ml of 50% glucose (or 25g glucose) 1, 2
• Beta-2 agonists: Salbutamol/albuterol 10-20 mg nebulized 1
• Sodium bicarbonate (if metabolic acidosis present): 50 mEq IV 1

Important: These measures provide only temporary reduction (1-4 hours) and must be followed by definitive treatment to remove potassium from the body 1

2. Potassium Elimination Methods

• Loop diuretics: Furosemide IV/oral to increase renal K+ excretion 1
• Potassium binders:
  • Sodium polystyrene sulfonate (15-60g orally or 30-50g rectally) 1, 3
  • Newer agents: Patiromer, sodium zirconium cyclosilicate 1
• Hemodialysis: Most effective for severe, refractory hyperkalemia, especially in kidney failure 1, 2

Important Caveats

• Sodium polystyrene sulfonate should not be used for emergency treatment due to its delayed onset of action 3
• Avoid sorbitol with sodium polystyrene sulfonate due to risk of intestinal necrosis 3
• Take other oral medications at least 3 hours before or after sodium polystyrene sulfonate 3
• Monitor for rebound hyperkalemia 2 hours after temporary measures 1
• Calcium administration is contraindicated in patients on digoxin 2
• Monitor for hypoglycemia when using insulin therapy

Chronic Management

1. Identify and address underlying causes:

   • Review medications (ACE inhibitors, ARBs, MRAs, NSAIDs, beta-blockers)
   • Evaluate kidney function
   • Assess for endocrine disorders (hypoaldosteronism)

2. Dietary modifications:

   • Restrict high-potassium foods
   • Avoid salt substitutes and potassium supplements

3. Medication adjustments:

   • Consider dose reduction of RAAS inhibitors rather than complete discontinuation when possible 1
   • For patients with cardiovascular disease requiring RAAS inhibitors, consider chronic use of potassium binders when K+ >5.0 mEq/L 1

4. Monitoring protocol:

   • Regular potassium level checks (frequency based on risk factors)
   • More frequent monitoring when initiating or adjusting medications that affect potassium

Special Considerations

• In patients with heart failure or chronic kidney disease on RAAS inhibitors, consider newer potassium binders (patiromer, sodium zirconium cyclosilicate) to maintain these beneficial medications 1, 4
• Patients with diabetes may require higher glucose doses with insulin therapy
• For patients sensitive to sodium load (heart failure, severe hypertension), calcium polystyrene sulfonate may be preferred over sodium polystyrene sulfonate 1

By following this structured approach to hyperkalemia management, clinicians can effectively address this potentially life-threatening condition while minimizing complications and optimizing long-term outcomes.