What are the treatment options for hyperkalemia?

Treatment Options for Hyperkalemia

The treatment of hyperkalemia should follow a systematic approach based on severity, with immediate stabilization of cardiac membranes using calcium gluconate for severe or symptomatic cases, followed by insulin with glucose and inhaled beta-agonists to shift potassium intracellularly, and ultimately removal of excess potassium from the body through diuretics, potassium binders, or hemodialysis. 1

Assessment and Classification of Hyperkalemia

Hyperkalemia severity can be classified as:

• Mild: 5.0-5.9 mEq/L
• Moderate: 6.0-6.4 mEq/L
• Severe: ≥6.5 mEq/L

ECG changes correlate with severity:

• 5.5-6.5 mmol/L: Peaked/tented T waves, nonspecific ST-segment abnormalities
• 6.5-7.5 mmol/L: PR interval prolongation, P wave flattening or absence
• 7.0-8.0 mmol/L: QRS widening, deepened S waves, merging of S and T waves

• 10 mmol/L: Sine wave pattern, ventricular fibrillation, asystole or pulseless electrical activity 1

Emergency Treatment for Severe or Symptomatic Hyperkalemia

Step 1: Cardiac Membrane Stabilization

• Calcium gluconate: 10% solution, 15-30 mL IV
  • Onset: 1-3 minutes
  • Duration: 30-60 minutes
  • Purpose: Protects the heart from arrhythmias by stabilizing cardiac membranes 1, 2

Step 2: Intracellular Shift of Potassium

• Insulin with glucose: 10 units regular insulin IV with 50 mL of 25% dextrose

  • Onset: 15-30 minutes
  • Duration: 1-2 hours 1, 3

• Inhaled beta-agonists: 10-20 mg nebulized albuterol over 15 minutes

  • Onset: 15-30 minutes
  • Duration: 2-4 hours
  • Can be used alone or in combination with insulin/glucose 1, 4

• Sodium bicarbonate: 50 mEq IV over 5 minutes

  • Onset: 15-30 minutes
  • Duration: 1-2 hours
  • Most effective in patients with metabolic acidosis 1, 5

Potassium Removal Strategies

Step 3: Elimination of Potassium from the Body

• Loop diuretics: 40-80 mg IV furosemide

  • Onset: 30-60 minutes
  • Duration: 2-4 hours
  • Effective only in patients with adequate renal function 1, 3

• Potassium binders:

  • Sodium polystyrene sulfonate (SPS): 15-60g orally or 30-50g rectally
    • Not for emergency treatment due to delayed onset of action
    • Should be taken at least 3 hours before or after other oral medications
    • Contraindicated in obstructive bowel disease 6, 7
  • Newer potassium binders (patiromer, sodium zirconium cyclosilicate)
    • Preferred over SPS due to improved safety profile 1

• Hemodialysis:

  • Most reliable method for potassium removal
  • Indicated for:
    • Severe hyperkalemia (>6.5 mEq/L) resistant to medical therapy
    • Persistent ECG changes despite treatment
    • Oliguric/anuric renal failure
    • End-stage renal disease 1, 2

Long-term Management

• Identify and address underlying causes:

  • Medication review (ACE inhibitors, ARBs, potassium-sparing diuretics, NSAIDs)
  • Renal function assessment
  • Hormonal disorders (e.g., hypoaldosteronism) 7

• Dietary modifications:

  • Low potassium diet (<2g/day)
  • Sodium restriction (<2g/day)
  • Regular physical activity (150 min/week)
  • Weight reduction if overweight/obese 1

• Monitoring:

  • Serum potassium: Within 1 week of treatment initiation
  • More frequent monitoring in high-risk patients (CKD, heart failure, diabetes)
  • Regular assessment of renal function 1

Important Caveats

• Sodium polystyrene sulfonate should not be used as an emergency treatment for life-threatening hyperkalemia due to its delayed onset of action 6
• Concomitant use of sorbitol with SPS may increase risk of intestinal necrosis and is not recommended 6
• Absent or atypical ECG changes do not exclude the need for immediate intervention in severe hyperkalemia 3
• In patients on RAAS inhibitors with hyperkalemia, therapy is usually not stopped but may be reduced or discontinued in severe cases 1
• Combination therapy (insulin/glucose plus beta-agonist) may be more effective than single agents alone 3