What is the treatment for hyperkalemia?

Treatment of Hyperkalemia

The treatment of hyperkalemia requires immediate stabilization of cardiac membranes with IV calcium gluconate, followed by shifting potassium intracellularly with insulin/glucose, and ultimately removing excess potassium from the body through various elimination methods. 1

Classification and Assessment

Hyperkalemia is classified as:

• Mild: 5.0-5.5 mmol/L
• Moderate: 5.6-6.5 mmol/L
• Severe: >6.5 mmol/L 1

ECG changes correlate with potassium levels:

• 5.5-6.5 mmol/L: Peaked/tented T waves
• 6.5-7.5 mmol/L: Prolonged PR interval, flattened P waves
• 7.0-8.0 mmol/L: Widened QRS, deep S waves

• 10 mmol/L: Sinusoidal pattern, VF, asystole, or PEA 1

Treatment Algorithm

Step 1: Cardiac Membrane Stabilization (Immediate)

• Administer IV calcium gluconate 10% solution (15-30 mL)
• Onset: 1-3 minutes
• Duration: 30-60 minutes
• Note: Calcium gluconate has been shown to be effective for main rhythm disorders due to hyperkalemia, though less effective for non-rhythm ECG disorders 2

Step 2: Intracellular Shift of Potassium (15-30 minutes)

• Administer 10 units regular insulin IV with 50 mL of 25% dextrose
• Onset: 15-30 minutes
• Duration: 1-2 hours
• Consider adjunctive therapy with inhaled beta-agonists (10-20 mg nebulized over 15 minutes)
• Consider sodium bicarbonate (50 mEq IV over 5 minutes) if metabolic acidosis is present 1

Step 3: Potassium Elimination (Hours)

• For non-emergency hyperkalemia:

  • Sodium polystyrene sulfonate: 15-60g daily in divided doses (oral) or 30-50g every 6 hours (rectal) 3
  • Note: Not for emergency treatment due to delayed onset 3
  • Newer potassium binders (patiromer, sodium zirconium cyclosilicate) have improved selectivity and fewer side effects 1, 4

• For severe or refractory hyperkalemia:

  • Hemodialysis: Most rapid and effective method for eliminating potassium 1, 5
  • Loop diuretics: Promote renal excretion of potassium 1

Special Considerations

Medication Administration

• Administer sodium polystyrene sulfonate at least 3 hours before or after other oral medications (6 hours for patients with gastroparesis) 3
• Prepare suspension fresh and use within 24 hours 3
• Do not heat sodium polystyrene sulfonate as it could alter the exchange properties 3

Contraindications for Sodium Polystyrene Sulfonate

• Hypersensitivity to polystyrene sulfonate resins
• Obstructive bowel disease
• Neonates with reduced gut motility 3

Risk Factors for Hyperkalemia

• Renal dysfunction
• Advanced age
• Male gender
• Diabetes mellitus
• Heart failure
• Medications: ACE inhibitors, ARBs, beta blockers, mineralocorticoid receptor antagonists, NSAIDs 1

Monitoring and Follow-up

• Check potassium and renal function within 1-2 weeks of initiating or changing ACE inhibitor dose
• Monitor potassium levels at least monthly for the first 3 months, then every 3 months thereafter 1

Lifestyle Modifications

• Counsel patients to avoid high-potassium foods
• Discontinue potassium supplements
• Avoid NSAIDs
• Maintain adequate hydration
• Limit dietary potassium to <40 mg/kg/day 1

Common Pitfalls

• Relying solely on sodium polystyrene sulfonate for emergency treatment (it has delayed onset of action) 3, 5
• Complete discontinuation of RAAS inhibitors without attempting dose reduction first 1
• Failure to monitor potassium levels after initiating treatment 1
• Overlooking drug interactions that can worsen hyperkalemia 1
• Ignoring renal function when treating hyperkalemia 1

Remember that hyperkalemia with potassium level >6.5 mEq/L or ECG changes is a medical emergency requiring immediate treatment 6. The most reliable agents for acute management are calcium for membrane stabilization and insulin for intracellular potassium shift, while hemodialysis remains the most effective method for potassium removal 5, 7.