From the Guidelines
Corticosteroids, specifically mineralocorticoid antagonists like spironolactone and eplerenone, can cause hyperkalemia by reducing potassium excretion in the kidneys. The mechanism behind steroid-induced hyperkalemia involves interference with the renin-angiotensin-aldosterone system, which normally regulates potassium balance by promoting potassium excretion in the distal tubule of the kidney 1. Typical doses of spironolactone range from 25-100 mg daily, while eplerenone is usually prescribed at 25-50 mg daily. Other steroid-related medications that may cause hyperkalemia include calcineurin inhibitors (tacrolimus, cyclosporine) and heparin, which can suppress aldosterone production. Some key points to consider:
- Patients taking these medications should have their potassium levels monitored regularly, especially those with risk factors such as kidney disease, diabetes, or concurrent use of other potassium-sparing medications like ACE inhibitors or ARBs.
- Conversely, glucocorticoids like prednisone and cortisone typically cause potassium to move into cells and may actually lower serum potassium levels.
- The clinical management of hyperkalemia may involve the use of loop or thiazide diuretics, modification of RAASi dose, and removal of other hyperkalemia-causing medications.
- It is essential to weigh the benefits and risks of RAASi therapy, as discontinuation or dose reduction may lead to adverse cardiorenal outcomes 1. Some medications that can cause hyperkalemia include:
- Potassium-sparing diuretics (e.g. spironolactone, triamterene, amiloride)
- Beta-blockers
- NSAIDs
- Sacubitril/valsartan
- Renin-angiotensin-aldosterone inhibitors (RAASi): ACE inhibitors, angiotensin receptor blockers, mineralocorticoid receptor antagonists (MRAs)
- Direct renin inhibitors (aliskiren)
- Mannitol
- Cyclosporine or tacrolimus
- Pentamidine
- Trimethoprim-sulfamethoxazole
- Heparin
- Digitalis
- Calcineurin inhibitors
- Penicillin G 1. Treatment of hyperkalemia may involve:
- Promoting the uptake of K+ into the intracellular space using b2-adrenergic agonists, insulin, or sodium bicarbonate
- Cardiac membrane stabilization with calcium chloride or gluconate
- Increasing K+ elimination using loop diuretics, haemodialysis, or cation-exchange resins 1.
From the Research
Corticosteroids and Hyperkalemia
- The provided studies do not suggest that corticosteroids cause hyperkalemia. Instead, they indicate that certain corticosteroids, such as fludrocortisone, can be used to treat hyperkalemia 2, 3, 4, 5.
- Fludrocortisone, a mineralocorticoid, has been shown to effectively reduce serum potassium levels in patients with hyperkalemia, including those with chronic kidney disease and end-stage renal disease 2, 3, 4, 5.
- The mechanism of action of fludrocortisone in reducing serum potassium levels is thought to be related to its mineralocorticoid activity, which promotes the excretion of potassium in the urine 5.
- However, it is worth noting that fludrocortisone therapy can be associated with adverse effects, such as sodium retention and edema 3, 6.
- In some cases, fludrocortisone therapy has been reported to cause severe hypokalemia and metabolic alkalosis, highlighting the need for careful monitoring and dose adjustment 6.