What is the treatment for hyperkalemia?

Hyperkalemia Treatment

The treatment of hyperkalemia requires a stepwise approach based on severity, with calcium gluconate for cardiac stabilization, insulin with glucose for intracellular potassium shifting, and potassium binders for long-term management, while sodium polystyrene sulfonate should not be used for emergency treatment due to its delayed onset of action. 1, 2

Immediate Management Based on Severity

Severe/Life-Threatening Hyperkalemia (K+ >6.5 mmol/L or ECG changes)

1. Cardiac Membrane Stabilization

   • Calcium gluconate 10% solution, 15-30 mL IV over 1-3 minutes
   • Onset: 1-3 minutes; Duration: 30-60 minutes 1
   • Note: This does not lower potassium but protects the heart

2. Intracellular Shifting of Potassium

   • Regular insulin 10 units IV with 25-50g dextrose (D50W)
   • Onset: 15-30 minutes; Duration: 1-2 hours 1
   • For pediatric patients: 0.1 unit/kg insulin with 400 mg/kg glucose 1
   • Consider adding inhaled beta-agonists (10-20 mg nebulized over 15 minutes) for enhanced effect 1
   • Sodium bicarbonate (50 mEq IV) may be used, particularly in acidotic patients 1

3. Potassium Removal

   • Loop diuretics (if renal function adequate): 40-80 mg IV 1
   • Hemodialysis for severe, refractory cases or renal failure 1

Moderate Hyperkalemia (K+ 5.5-6.5 mmol/L without ECG changes)

• Use insulin/glucose and/or inhaled beta-agonists
• Consider oral potassium binders for ongoing management
• Monitor potassium levels closely

Long-Term Management

1. Potassium Binders

   • Preferred agents: Lokelma (sodium zirconium cyclosilicate) or Veltassa (patiromer) 1
   • Sodium polystyrene sulfonate (Kayexalate): Not recommended for emergency treatment due to delayed onset and potential for intestinal necrosis 1, 2
   • Dosing for sodium polystyrene sulfonate: 15-60g orally daily (divided doses) or 30-50g rectally every 6 hours 2

2. Medication Review

   • Identify and modify medications contributing to hyperkalemia:
     • RAASi (ACE inhibitors, ARBs, MRAs)
     • Potassium-sparing diuretics
     • NSAIDs
     • Beta-blockers
     • Calcineurin inhibitors 1

3. Dietary Modifications

   • Restrict potassium intake
   • Provide dietary counseling

Monitoring and Follow-up

• Schedule follow-up potassium measurement within 1 week of treatment initiation 1
• More frequent monitoring for high-risk patients (CKD, heart failure, diabetes) 1
• Watch for rebound hyperkalemia 2-4 hours after treatments that shift potassium intracellularly 1

Important Clinical Considerations

• Do not rely solely on ECG changes to guide treatment decisions - absence of typical ECG changes does not exclude severe hyperkalemia 1
• Sodium polystyrene sulfonate should not be used for emergency treatment of life-threatening hyperkalemia due to its delayed onset of action 2
• For patients taking medications that cause hyperkalemia (especially RAASi):
  • If K+ >5.0-<6.5 mmol/L: Consider potassium-lowering agents while maintaining RAASi therapy 1
  • If K+ >6.5 mmol/L: Discontinue or reduce RAASi therapy and initiate potassium-lowering agents 1
• When using sodium polystyrene sulfonate, take other oral medications at least 3 hours before or after to prevent drug interactions 2
• Avoid concomitant use of sodium polystyrene sulfonate with sorbitol due to risk of intestinal necrosis 2