What are the treatment options for hyperkalemia (elevated potassium levels)?

From the Guidelines

Treatment for hyperkalemia should prioritize immediate interventions to lower potassium levels and prevent life-threatening complications, with calcium gluconate, insulin, and beta-2 agonists being key initial treatments, as recommended by the most recent and highest quality study 1.

Key Treatment Options

• For mild hyperkalemia (5.5-6.0 mEq/L), dietary potassium restriction and discontinuation of potassium-sparing medications may be sufficient.
• For moderate to severe hyperkalemia (>6.0 mEq/L), more aggressive interventions are needed, including:
  • Calcium gluconate (10 mL of 10% solution IV over 2-3 minutes) to stabilize cardiac membranes and prevent arrhythmias.
  • Insulin with glucose (10 units regular insulin with 25g dextrose IV) to drive potassium into cells temporarily, lowering serum levels within 15-30 minutes.
  • Inhaled beta-2 agonists like albuterol (10-20 mg nebulized) to shift potassium intracellularly.

Definitive Removal of Potassium

• Sodium polystyrene sulfonate (15-30g orally or rectally) exchanges sodium for potassium in the gut.
• Loop diuretics like furosemide (40-80mg IV) increase renal potassium excretion in patients with adequate kidney function.
• Hemodialysis is the most effective method for severe or refractory hyperkalemia, especially in patients with kidney failure.

Ongoing Management

• Ongoing monitoring of potassium levels, ECG changes, and addressing the underlying cause (such as medication effects, renal failure, or adrenal disorders) are essential components of comprehensive management, as emphasized by 1 and 1.
• Individualized monitoring of serum K+ among patients with an increased risk of hyperkalemia and the use of newer K+-binding agents, such as patiromer sorbitex calcium and sodium zirconium cyclosilicate, may allow for optimization of RAASi therapy and more effective management of hyperkalemia, as suggested by 1.

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 treatment option for hyperkalemia is sodium polystyrene sulfonate, a potassium binder. However, it should not be used as an emergency treatment for life-threatening hyperkalemia due to its delayed onset of action 2 2.

• The average total daily adult dose is 15 g to 60 g, administered orally as a 15 g dose, one to four times daily.
• The average adult dose for rectal administration is 30 g to 50 g every six hours.

From the Research

Treatment Options for Hyperkalemia

The treatment options for hyperkalemia include:

• Elimination of reversible causes (diet, medications) 3
• Rapidly acting therapies that shift potassium into cells and block the cardiac membrane effects of hyperkalemia, such as:
  • Calcium gluconate to stabilize cardiomyocyte membranes 3, 4, 5
  • Insulin injection, usually with concomitant glucose, to lower serum potassium levels 3, 4, 6, 5
  • Beta-2 agonists administration, such as albuterol or salbutamol, to induce a shift of potassium into the intracellular compartment 3, 6, 5
• Measures to facilitate removal of potassium from the body, such as:
  • Saline diuresis 3
  • Oral binding resins, such as sodium polystyrene sulfonate (SPS), sodium zirconium cyclosilicate (SZC), and patiromer 7, 4
  • Hemodialysis, which remains the most reliable method to remove potassium from the body 3, 5

Urgent Treatment Indications

Indications for urgent treatment of hyperkalemia include:

• Severe or symptomatic hyperkalemia 4
• Abrupt changes in potassium levels 4
• Electrocardiography changes 3, 4, 5
• Presence of certain comorbid conditions, such as kidney disease or hyperglycemia 4

Additional Management Steps

Additional management steps for hyperkalemia include:

• Stopping further potassium intake 5
• Careful review of prescribed drugs that may be adversely affecting potassium homeostasis 5
• Changes to prescribing systems and an agreed institutional protocol for management of hyperkalemia to improve patient safety 5