From the Guidelines
Hyperkalemia management involves a stepwise approach, prioritizing immediate intervention for severe cases (≥7.0 mEq/L) or with ECG changes, using calcium gluconate and insulin to stabilize cardiac membranes and shift potassium intracellularly, as recommended by the most recent and highest quality study 1.
Key Considerations
- For mild hyperkalemia (5.5-6.0 mEq/L), restrict dietary potassium and discontinue potassium-sparing medications.
- For moderate hyperkalemia (6.1-6.9 mEq/L), administer oral sodium polystyrene sulfonate (Kayexalate) 15-30g or patiromer 8.4g, along with loop diuretics like furosemide 40-80mg IV if renal function permits.
- Severe hyperkalemia requires immediate intervention with calcium gluconate 10% 10-30mL IV over 2-3 minutes, followed by insulin 10 units IV with 50mL of 50% dextrose, and consideration of nebulized albuterol 10-20mg.
- Ongoing management may include sodium bicarbonate 50mEq IV for acidotic patients, and hemodialysis for refractory hyperkalemia or severe renal failure.
Mechanisms of Action
- Calcium gluconate stabilizes cardiac membranes.
- Insulin and glucose, as well as albuterol, drive potassium into cells.
- Binders like Kayexalate and patiromer, and dialysis, remove potassium from the body.
Monitoring and Adjustment
- Regular potassium monitoring is crucial to assess treatment efficacy and adjust therapy as needed.
- Consideration of the patient's diet, use of supplements, and concomitant medications that may contribute to hyperkalemia is essential.
- The use of newer K+ binders, such as patiromer and sodium zirconium cyclosilicate, may facilitate optimization of RAASi therapy and more effective management of hyperkalemia, as suggested by recent clinical studies 1.
From the FDA Drug Label
12. 1 Mechanism of Action Veltassa is a non-absorbed, cation exchange polymer that contains a calcium-sorbitol counterion. Veltassa increases fecal potassium excretion through binding of potassium in the lumen of the gastrointestinal tract. Binding of potassium reduces the concentration of free potassium in the gastrointestinal lumen, resulting in a reduction of serum potassium levels. In an open-label, uncontrolled study, 25 patients with hyperkalemia (mean baseline serum potassium of 5.9 mEq/L) and chronic kidney disease were given a controlled potassium diet for 3 days, followed by 16. 8 grams patiromer daily (as divided doses) for 2 days while the controlled diet was continued. A statistically significant reduction in serum potassium (-0.2 mEq/L) was observed at 7 hours after the first dose. Serum potassium levels continued to decline during the 48-hour treatment period (-0. 8 mEq/L at 48 hours after the first dose).
The protocol for managing Hyperkalemia (elevated potassium levels) using Veltassa (patiromer) involves:
- Administering 16.8 grams of patiromer daily, as divided doses, to patients with hyperkalemia and chronic kidney disease
- Maintaining a controlled potassium diet
Monitoring serum potassium levels, which may decrease significantly within 7 hours and continue to decline over 48 hours of treatment 2
Note that calcium chloride may also be used to combat the deleterious effects of hyperkalemia, but there is limited clinical evidence to support this indication 3
From the Research
Protocols for Managing Hyperkalemia
The management of hyperkalemia involves several key steps, including:
- Stabilization of cardiac membranes using calcium gluconate 10% dosed 10 mL intravenously, unless the patient is in cardiac arrest, in which case 10 mL calcium chloride is warranted 4
- Shifting potassium from extracellular to intracellular stores using beta-agonists and intravenous insulin, with some experts recommending the use of synthetic short-acting insulins rather than regular insulin 4
- Promoting potassium excretion through dialysis, loop and thiazide diuretics, and new medications such as patiromer and sodium zirconium cyclosilicate 4, 5, 6
Treatment Options
Treatment options for hyperkalemia include:
- Glucose and insulin to lower serum potassium levels 5, 7, 8
- Bicarbonate to help shift potassium into cells 5
- Beta-2 agonists to augment the effects of intravenous insulin and glucose 8
- Hyperventilation to help reduce serum potassium levels 5
- Dialysis to remove excess potassium from the body 4, 8
Medications for Hyperkalemia
Several medications are available to help manage hyperkalemia, including: