What is the treatment for hyperkalemia?

Management of Hyperkalemia with Potassium Level of 5.5

For a potassium level of 5.5 mEq/L (moderate hyperkalemia), initiate a potassium-lowering agent while maintaining RAAS inhibitor therapy if applicable, with close monitoring of potassium levels. 1

Initial Assessment and Treatment Strategy

Severity Classification

• Mild hyperkalemia: >5.0 to <5.5 mEq/L
• Moderate hyperkalemia: 5.5 to 6.0 mEq/L (patient's current level)
• Severe hyperkalemia: >6.0 mEq/L 1

Immediate Management Steps

1. Check ECG for signs of hyperkalemia (peaked T waves, widened QRS, prolonged PR interval)

2. Review medications that may contribute to hyperkalemia:

   • RAAS inhibitors (ACE inhibitors, ARBs)
   • Mineralocorticoid receptor antagonists (spironolactone, eplerenone)
   • NSAIDs
   • Beta-blockers
   • Calcineurin inhibitors
   • Heparin and derivatives 1, 2

3. Evaluate kidney function as renal impairment is a common contributor to hyperkalemia

Treatment Options

For Moderate Hyperkalemia (5.5 mEq/L)

1. Potassium-binding agents:

   • Sodium zirconium cyclosilicate (SZC): Effective at reducing serum K+ within 1 hour with a 10g dose 3
   • Patiromer: Recommended by American College of Cardiology as first-line therapy 1
   • Sodium polystyrene sulfonate: Note that this should not be used for emergency treatment due to delayed onset of action 4

2. Dietary modifications:

   • Restrict high-potassium foods (bananas, oranges, potatoes, tomatoes)
   • Avoid salt substitutes containing potassium chloride 1

3. Diuretic therapy:

   • Consider loop diuretics to enhance potassium excretion 1

4. RAAS inhibitor management:

   • For K+ levels of >5.0–<6.5 mEq/L on RAAS inhibitor therapy, maintain treatment while initiating potassium-lowering agent 3
   • Only consider reducing or discontinuing RAAS inhibitors if K+ exceeds 6.5 mEq/L 3, 1

Monitoring and Follow-up

• Check potassium levels within 1 week of treatment initiation 1
• Monitor more frequently in patients with CKD, heart failure, or diabetes
• Watch for rebound hyperkalemia 2-4 hours after treatments that shift potassium intracellularly 1
• Evaluate volume status using orthostatic vital signs, jugular venous pressure, and peripheral edema

Special Considerations

• For patients on RAAS inhibitors: The European Heart Journal recommends maintaining RAAS inhibitor therapy when K+ is >5.0–<6.5 mEq/L while initiating potassium-lowering agents 3
• For patients with heart failure: Prioritize maintaining RAAS inhibitors due to mortality benefit, using potassium binders to enable continued therapy 1
• For patients with CKD: More aggressive potassium management may be required 1

Common Pitfalls to Avoid

• Don't rely solely on ECG changes to guide treatment decisions, as severe hyperkalemia can exist without typical ECG findings 1
• Don't overlook pseudo-hyperkalemia caused by hemolysis during blood collection; repeat measurement if suspected 1
• Don't permanently discontinue beneficial RAAS inhibitors if potassium is <6.5 mEq/L; instead, use potassium-lowering agents to maintain therapy 3, 1
• Don't underestimate the importance of medication review as drug-induced hyperkalemia is the most important cause of increased potassium levels in clinical practice 2