From the FDA Drug Label
Acetazolamide therapy is contraindicated in situations in which sodium and/or potassium blood serum levels are depressed, in cases of marked kidney and liver disease or dysfunction, in suprarenal gland failure, and in hyperchloremic acidosis.
The FDA drug label does not answer the question when Acetazolamide (Diamox) is indicated in hyperkalemia, it actually lists a contraindication for use in certain electrolyte imbalances but does not provide information on its use for hyperkalemia.
From the Research
Acetazolamide is not typically indicated for the treatment of hyperkalemia, and its use may even worsen the condition in some cases. The standard treatments for hyperkalemia include insulin with glucose, beta-agonists like albuterol, calcium gluconate or calcium chloride, sodium bicarbonate, loop or thiazide diuretics, and potassium binders such as sodium polystyrene sulfonate, patiromer, or sodium zirconium cyclosilicate 1. Acetazolamide is a carbonic anhydrase inhibitor primarily used for conditions like glaucoma, altitude sickness, and certain types of metabolic alkalosis. It can actually worsen hyperkalemia in some cases by causing a mild acidosis, which promotes potassium shift from intracellular to extracellular space.
In patients with hyperkalemia, especially in emergency situations, clinicians should focus on established treatments that rapidly lower serum potassium levels through redistribution into cells or elimination from the body. The only theoretical scenario where acetazolamide might be considered is in a patient with concurrent severe metabolic alkalosis and hyperkalemia, but even then, other treatments would typically be prioritized for the hyperkalemia component. According to a study published in 2022, potassium binders such as sodium zirconium cyclosilicate and calcium polystyrene sulfonate are effective in reducing plasma potassium concentrations in patients with hyperkalemia 2.
Some studies have explored the use of acetazolamide in various conditions, including metabolic alkalosis and periodic hypokalemic paralysis 3, 4. However, these studies do not support the use of acetazolamide as a primary treatment for hyperkalemia. In fact, a study published in 1999 found that acetazolamide can effectively reverse metabolic alkalosis, but its use in hyperkalemia is not recommended 3.
Key points to consider when managing hyperkalemia include:
- Identifying and treating the underlying cause of hyperkalemia
- Using established treatments that rapidly lower serum potassium levels
- Avoiding the use of acetazolamide as a primary treatment for hyperkalemia
- Considering the use of potassium binders and other treatments that are effective in reducing plasma potassium concentrations. It is essential to prioritize the most recent and highest quality evidence when making treatment decisions, and in this case, the evidence suggests that acetazolamide is not a recommended treatment for hyperkalemia 1.