Hyperkalemia Treatment
The treatment of hyperkalemia requires a stepwise approach based on severity, with immediate administration of calcium gluconate for cardiac membrane stabilization in severe cases, followed by insulin with glucose and inhaled beta-agonists for potassium redistribution, and finally potassium binders or hemodialysis for potassium elimination. 1
Classification and Initial Assessment
Hyperkalemia severity:
- Mild: 5.5-6.0 mmol/L
- Moderate: 6.1-6.5 mmol/L
- Severe: >6.5 mmol/L or with ECG changes 1
ECG findings to monitor:
- Peaked T waves
- Prolonged PR interval
- Widened QRS complex
- Sine wave pattern (pre-terminal)
CAUTION: Absence of ECG changes does not exclude severe hyperkalemia 1
Acute Treatment Algorithm
1. Cardiac Membrane Stabilization (for severe hyperkalemia or ECG changes)
- Calcium gluconate: 10% solution, 15-30 mL IV
- Onset: 1-3 minutes
- Duration: 30-60 minutes 1
2. Intracellular Potassium Shift
Insulin with glucose: 10 units regular insulin IV with 25-50g of dextrose (D50W)
Inhaled beta-agonists: 10-20 mg albuterol nebulized over 15 minutes
- Onset: 15-30 minutes
- Duration: 2-4 hours 1
Sodium bicarbonate: 50 mEq IV over 5 minutes
- Primarily indicated if concomitant metabolic acidosis
- Onset: 15-30 minutes
- Duration: 1-2 hours 1
3. Potassium Elimination
Loop diuretics: 40-80 mg IV furosemide
- Effective only if renal function is adequate
- Onset: 30-60 minutes
- Duration: 2-4 hours 1
Potassium binders:
- Patiromer (Veltassa)
- Sodium zirconium cyclosilicate (Lokelma)
- Sodium polystyrene sulfonate: 15-60g orally or 30-50g rectally
CAUTION: Not for emergency treatment due to delayed onset 2
Hemodialysis: Most effective for refractory cases or severe renal dysfunction 1
Treatment Based on Severity
Mild Hyperkalemia (5.5-6.0 mmol/L)
- Evaluate and address underlying causes
- Loop or thiazide diuretics if renal function adequate
- Consider potassium binders for chronic management
- Monitor potassium levels
Moderate Hyperkalemia (6.1-6.5 mmol/L)
- All measures for mild hyperkalemia
- Consider insulin/glucose and/or nebulized beta-agonists
- Initiate potassium binders
Severe Hyperkalemia (>6.5 mmol/L or with ECG changes)
- Immediate calcium gluconate administration
- Insulin/glucose AND nebulized beta-agonists
- Consider sodium bicarbonate if metabolic acidosis present
- Urgent hemodialysis if refractory or severe renal dysfunction 3, 1
Special Considerations for Patients on RAASi Therapy
For patients on renin-angiotensin-aldosterone system inhibitors (RAASi) with hyperkalemia:
- K+ levels >5.0-<6.5 mmol/L: Initiate approved K+-lowering agent while maintaining RAASi therapy 3
- K+ levels >6.5 mmol/L: Discontinue/reduce RAASi and initiate K+-lowering agent 3
- Once K+ levels normalize (<5.0 mmol/L), consider up-titrating RAASi while maintaining K+-lowering treatment 3
Monitoring and Prevention of Complications
Hypoglycemia risk: Monitor blood glucose hourly for 4-6 hours after insulin administration
- Higher risk in patients with pretreatment blood glucose <110 mg/dL or no diabetes history 1
Rebound hyperkalemia: May occur 2-4 hours after treatments that shift potassium intracellularly 1
Follow-up monitoring: Schedule potassium measurement within 1 week of treatment initiation
- More frequent monitoring for patients with CKD, heart failure, or diabetes 1
Prevention of Recurrence
Evaluate and address underlying causes:
- Medication review (RAAS inhibitors, NSAIDs, potassium-sparing diuretics)
- Dietary potassium restriction
- Treatment of metabolic acidosis
- Management of underlying kidney disease
For chronic or recurrent hyperkalemia:
CAUTION: Sodium polystyrene sulfonate should not be used as emergency treatment for life-threatening hyperkalemia due to its delayed onset of action 2