How do you treat hyperkalemia?

Treatment of Hyperkalemia

For hyperkalemia treatment, administer IV calcium gluconate 10% solution (15-30 mL) to stabilize cardiac membranes, followed immediately by insulin with glucose (10 units regular insulin IV with 50 mL of 25% dextrose) to shift potassium intracellularly. 1

Severity Assessment and Initial Management

Treatment approach depends on severity of hyperkalemia:

• Mild (5.0-5.5 mmol/L): Monitor closely, address underlying causes
• Moderate (5.6-6.5 mmol/L): Active treatment required
• Severe (>6.5 mmol/L): Urgent intervention needed 1

Emergency Treatment Algorithm (Severe Hyperkalemia)

1. Stabilize cardiac membrane:

   • Calcium gluconate 10% solution, 15-30 mL IV
   • Onset: 1-3 minutes, Duration: 30-60 minutes
   • Protects against cardiac arrhythmias while other treatments take effect 1

2. Shift potassium intracellularly:

   • Insulin with glucose: 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) 1
   • If metabolic acidosis present: Sodium bicarbonate 50 mEq IV over 5 minutes 1

3. Remove excess potassium:

   • Hemodialysis: Most rapid and effective method for eliminating potassium, especially for severe cases or when other treatments fail 1
   • Loop diuretics: Promote renal excretion of potassium (if renal function adequate) 1
   • Cation exchange resins: Sodium polystyrene sulfonate (SPS/Kayexalate) - Note: Not for emergency treatment due to delayed onset of action 2

Non-Emergency Management

Potassium Binders

• Sodium polystyrene sulfonate (SPS/Kayexalate):

  • Onset: Variable (several hours)
  • Not for emergency treatment of life-threatening hyperkalemia 2
  • Associated with serious gastrointestinal adverse effects 3

• Newer agents (for chronic or subacute hyperkalemia):

  • Patiromer: Onset ~7 hours, no sodium content
  • Sodium zirconium cyclosilicate (SZC/Lokelma): Faster onset (~1 hour) 1, 3

Monitoring and Follow-up

• Check ECG for hyperkalemia changes:

  • 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

• Monitor potassium levels:

  • Within 1-2 weeks of medication changes
  • At least monthly for first 3 months, then every 3 months thereafter 1

Addressing Underlying Causes

• Medication review: Evaluate and adjust medications that contribute to hyperkalemia:

  • RAAS inhibitors (ACE inhibitors, ARBs)
  • Beta blockers
  • Potassium-sparing diuretics
  • NSAIDs 1, 3

• Avoid triple RAAS blockade (ACE inhibitor/ARB + MRA + beta blocker) 1

• Consider dose reduction rather than complete discontinuation of beneficial RAAS inhibitors 1

Lifestyle Modifications

• Dietary counseling:

  • Limit dietary potassium to <40 mg/kg/day
  • Avoid high-potassium foods
  • Avoid potassium-containing salt substitutes 1, 3

• Food preparation techniques:

  • Pre-soaking root vegetables can reduce potassium content by 50-75% 1

• Other modifications:

  • Sodium restriction (<2g/day)
  • Regular physical activity (150 min/week)
  • Maintain adequate hydration 1

Common Pitfalls to Avoid

• Failing to recognize and treat life-threatening hyperkalemia promptly
• Using sodium polystyrene sulfonate for emergency treatment 2
• Completely discontinuing RAAS inhibitors without attempting dose reduction 1
• Inadequate monitoring of potassium levels after medication changes
• Overlooking drug interactions that increase hyperkalemia risk 1
• Ignoring renal function when treating hyperkalemia 1, 4

For patients with end-stage renal disease, severe renal impairment, or ongoing potassium release, hemodialysis should be considered as a primary treatment option 4, 3.