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

From the Guidelines

Severe hyperkalemia should be treated immediately with intravenous calcium gluconate to stabilize cardiac membranes, followed by interventions to shift potassium into cells and eliminate excess potassium from the body. According to the clinical management of hyperkalemia study published in the Mayo Clinic Proceedings in 2021 1, treatment options for acute hyperkalemia include intravenous calcium to reduce membrane excitation in cardiac tissue within 1 to 3 minutes.

Treatment Approach

The following steps should be taken to manage severe hyperkalemia:

• Administer calcium gluconate 10% solution (10 mL IV over 2-3 minutes) to stabilize cardiac membranes, which works within minutes but lasts only 30-60 minutes.
• Use interventions to shift potassium into cells, such as insulin (10 units regular insulin IV with 25g dextrose to prevent hypoglycemia) and nebulized albuterol (10-20 mg), as these measures can redistribute potassium to the intracellular space within 30 to 60 minutes 1.
• Implement strategies to eliminate potassium from the body, including sodium polystyrene sulfonate (15-30g orally or rectally), loop diuretics like furosemide (40-80mg IV) if kidney function is adequate, and hemodialysis for severe cases or when other measures fail.

Ongoing Management

It is essential to:

• Continuously monitor cardiac activity throughout treatment.
• Identify and address the underlying cause of hyperkalemia, which may include medication review (especially ACE inhibitors, ARBs, potassium-sparing diuretics), correction of acidosis, or treatment of renal failure.
• Repeat potassium measurements to guide ongoing management and prevent recurrence, as the effectiveness of treatment can vary depending on the individual patient's condition and response to therapy 1.

From the FDA Drug Label

The intensity and duration of therapy depend upon the severity and resistance of hyperkalemia. Oral The average total daily adult dose of Sodium Polystyrene Sulfonate Powder, for Suspension is 15 g to 60 g, administered as a 15-g dose (four level teaspoons), one to four times daily. Rectal The average adult dose is 30 g to 50 g every six hours.

The treatment for severe hyperkalemia with Sodium Polystyrene Sulfonate Powder, for Suspension is:

• Oral administration: 15 g to 60 g per day, given as 15-g doses, 1 to 4 times daily.
• Rectal administration: 30 g to 50 g every 6 hours. 2

From the Research

Treatment for Severe Hyperkalemia

The treatment for severe hyperkalemia involves several steps, including:

• Elimination of reversible causes, such as diet and medications 3
• Rapidly acting therapies to shift potassium into cells and block the cardiac membrane effects of hyperkalemia, such as calcium gluconate, insulin, and beta-2 agonists 3, 4, 5, 6
• Measures to facilitate removal of potassium from the body, such as saline diuresis, oral binding resins, and hemodialysis 3, 6

Emergency Treatment

In cases of severe hyperkalemia with potassium levels above 6.5 mEq/L or EKG changes, treatment should be started immediately with:

• Calcium gluconate to stabilize cardiomyocyte membranes 3, 5, 6
• Insulin injection to shift potassium into cells 3, 4, 5, 6
• Beta-2 agonists administration to further shift potassium into cells 3, 4, 5, 6

Removal of Potassium

Hemodialysis is the most reliable method to remove potassium from the body and should be used in cases refractory to medical treatment 3, 6 Other methods to remove potassium include:

• Diuretics, such as furosemide 6
• Cation exchange resin, such as kayexelate, with sorbitol 6

Long-term Management

Long-term management of hyperkalemia involves:

• Identifying and treating underlying causes, such as kidney failure or medications that inhibit the renin-angiotensin-aldosterone system 7, 5
• Preventing recurrence or worsening of hyperkalemia through dietary and medical management 7, 6