What is the treatment for hyperkalemia (elevated potassium levels)?

From the Guidelines

Hyperkalemia should be treated with immediate intervention, starting with calcium gluconate 10% (10 mL IV over 2-3 minutes) to stabilize cardiac membranes, followed by insulin and glucose administration to shift potassium intracellularly, as recommended by the most recent and highest quality study 1.

Treatment Approach

The treatment of hyperkalemia aims to protect the heart from the effects of hyperkalemia, shift potassium into cells, and remove potassium from the body.

• Stabilize myocardial cell membrane with calcium chloride (10%): 5 to 10 mL (500 to 1000 mg) IV over 2 to 5 minutes or calcium gluconate (10%): 15 to 30 mL IV over 2 to 5 minutes, as suggested by 1.
• Shift potassium into cells using sodium bicarbonate: 50 mEq IV over 5 minutes, although its use is limited to patients with metabolic acidosis, as noted in 1.

Management Strategies

For moderate to severe hyperkalemia (>6.0 mEq/L) or when ECG changes are present, the following management strategies can be employed:

• Administer insulin and glucose (10 units regular insulin IV with 25g dextrose) to shift potassium intracellularly.
• Use nebulized albuterol (10-20 mg) to promote intracellular potassium shift.
• Employ potassium removal methods such as sodium polystyrene sulfonate (15-30g orally or 30-50g rectally) or newer potassium binders like patiromer (8.4-25.2g daily) or sodium zirconium cyclosilicate (10g TID initially).
• Loop diuretics like furosemide (40-80mg IV) can enhance potassium excretion in patients with adequate kidney function.

Severe or Refractory Cases

For severe or refractory cases, hemodialysis is the most effective method for removing potassium from the body, as highlighted in 1. It is essential to address the underlying cause of hyperkalemia while managing the acute elevation.

From the FDA Drug Label

Sodium polystyrene sulfonate is a potassium binder indicated for the treatment of hyperkalemia Limitation of Use: Sodium polystyrene sulfonate should not be used an emergency treatment for life threatening hyperkalemia because of its delayed onset of action The average total daily adult dose of sodium polystyrene sulfonate is 15 g to 60 g, administered as a 15 g dose (four level teaspoons), one to four times daily The average adult dose is 30 g to 50 g every six hours

The treatment for hyperkalemia is sodium polystyrene sulfonate, a potassium binder, with a dose of 15 g to 60 g orally or 30 g to 50 g rectally every six hours 2 2. However, it should not be used as an emergency treatment for life-threatening hyperkalemia due to its delayed onset of action.

From the Research

Treatment Options for Hyperkalemia

• The treatment of hyperkalemia involves the elimination of reversible causes, rapidly acting therapies to shift potassium into cells and block cardiac membrane effects, and measures to facilitate potassium removal from the body 3.
• For acute hyperkalemia, treatment should be started with calcium gluconate to stabilize cardiomyocyte membranes, followed by insulin injection and β-agonists administration 3, 4.
• Hemodialysis remains the most reliable method to remove potassium from the body and should be used in cases refractory to medical treatment 3.
• A continuous infusion of a solution containing fixed concentrations of calcium gluconate, insulin, dextrose, and sodium acetate (HyperK-Cocktail) has been shown to be safe and effective for the treatment of hyperkalemia 5.
• Other treatment options include glucose and insulin, bicarbonate, beta-2 agonists, hyperventilation, and dialysis 6.

Management of Hyperkalemia

• Prompt recognition of hyperkalemia and administration of appropriate treatment can prevent serious cardiac complications 4.
• Treatment of life-threatening hyperkalemia involves administration of intravenous calcium salts to stabilize the resting cardiac membrane potential, followed by intravenous insulin combined with an infusion of glucose to stimulate intracellular uptake of potassium 4.
• Additional management steps include stopping further potassium intake and careful review of prescribed drugs that may be adversely affecting potassium homeostasis 4.
• For chronic hyperkalemia, the approach begins with a review of medications potentially responsible for the disorder, ensuring effective diuretic therapy, and correcting metabolic acidosis if present 7.

Pharmacotherapies for Hyperkalemia

• Several drugs, including sodium polystyrene sulfonate (SPS), sodium zirconium cyclosilicate (SZC), and patiromer, can aid in the reduction of serum potassium levels 6.
• These drugs have increased selectivity for potassium and work primarily in the gastrointestinal (GI) tract, each with unique benefits and contraindications 6.
• K+ binding drugs and sodium-glucose cotransporter 2 inhibitors can assist in maintaining the use of renin-angiotensin-aldosterone inhibitors, which improve outcomes in patients with heart failure and proteinuric kidney disease 7.