What are the treatment options for chronic hyperkalemia?

Treatment Options for Chronic Hyperkalemia

For chronic hyperkalemia management, treatment should include dietary potassium restriction, optimization of medications, and use of potassium binders such as patiromer or sodium zirconium cyclosilicate (SZC), with acute interventions as needed based on severity and ECG changes. 1

Initial Assessment and Stratification

• Assess severity of hyperkalemia:
  • Mild: 5.0-5.5 mmol/L
  • Moderate: 5.6-6.5 mmol/L
  • Severe: >6.5 mmol/L
• Check for ECG 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

Treatment Algorithm

1. Dietary Management

• Limit potassium intake to <40 mg/kg/day 1
• Avoid high-potassium foods: bananas, oranges, potatoes, tomato products, legumes, yogurt, chocolate
• Avoid potassium-containing salt substitutes
• Pre-soak root vegetables to reduce potassium content by 50-75% 1

2. Medication Review and Optimization

• Review and adjust medications that contribute to hyperkalemia
• Consider dose reduction of ACEi/ARBs rather than complete discontinuation 1
• Only discontinue ACEi/ARB if:
  • Serum creatinine rises by >30% within 4 weeks of initiation
  • Uncontrolled hyperkalemia despite medical treatment
  • Symptomatic hypotension occurs 1
• For patients with eGFR ≥20 mL/min/1.73 m², consider SGLT2 inhibitors for renal protection 1, 2

3. Potassium Binders

• FDA-approved options:

  • Patiromer (Veltassa)
  • Sodium zirconium cyclosilicate (Lokelma) 1, 3

• Comparison of potassium binders:

Characteristic	SPS	Patiromer	SZC
Onset of action	Variable; several hours	7 hours	1 hour
Site of action	Colon	Colon	Small and large intestines
Selectivity	Low (binds Ca²⁺, Mg²⁺)	Moderate (binds Na⁺, Mg²⁺)	High (mainly binds NH₄⁺)
Na⁺ content	1500mg per 15g dose	None	400mg per 5g dose
Serious AEs	Fatal GI injury reported	None reported	None reported
Most common AEs	GI disorders, electrolyte imbalances	GI disorders, hypomagnesemia	GI disorders, edema

• SZC (Lokelma) considerations:
  • Monitor for edema, especially in patients with heart failure or renal disease 3
  • Each 5g dose contains approximately 400mg of sodium 3
  • Avoid in patients with severe constipation, bowel obstruction or impaction 3
  • May cause hypokalemia, requiring dose adjustment 3
  • Administer other oral medications at least 2 hours before or after SZC 3

4. Acute Interventions (for severe or symptomatic hyperkalemia)

• Calcium gluconate: 10% solution, 15-30 mL IV (onset: 1-3 minutes, duration: 30-60 minutes)
• Insulin with glucose: 10 units regular insulin IV with 50 mL of 25% dextrose (onset: 15-30 minutes, duration: 1-2 hours)
• Inhaled beta-agonists: 10-20 mg nebulized over 15 minutes (onset: 15-30 minutes, duration: 2-4 hours)
• Sodium bicarbonate: 50 mEq IV over 5 minutes (onset: 15-30 minutes, duration: 1-2 hours) 1

Monitoring and Follow-up

• Check serum potassium and renal function within 2-4 days of initiating or adjusting therapy 1
• Monitor for hypokalemia, particularly with potassium binder use 1, 3
• Regular ECG monitoring is recommended to assess for hyperkalemia 1
• For patients on hemodialysis, consider adjusting potassium binder dose based on pre-dialysis potassium levels 3

Special Considerations

Patients with Heart Failure

• Beta blockers provide significant mortality benefits and should not be withheld solely due to mild hyperkalemia 1
• Consider cardioselective beta blockers (metoprolol, bisoprolol) rather than non-selective beta blockers 1
• Monitor for edema with SZC, especially in heart failure patients 3

Patients with Chronic Kidney Disease

• Newer potassium binders (patiromer, SZC) allow continued use of RAAS inhibitors in CKD patients 4, 5
• Consider SGLT2 inhibitors for additional renal protection and potassium management 2
• For severe renal impairment or end-stage renal disease, dialysis may be necessary for acute hyperkalemia management 6

Pitfalls and Caveats

• Do not rely solely on potassium binders for acute, severe hyperkalemia due to delayed onset of action 1
• Avoid abrupt discontinuation of RAAS inhibitors, as these medications provide important cardio-renal protection 1, 4
• Monitor for hypokalemia with potassium binder treatment, which may require dose adjustment 1, 3
• SZC can transiently increase gastric pH, potentially altering the absorption of co-administered drugs with pH-dependent solubility 3
• Sodium polystyrene sulfonate is associated with serious gastrointestinal adverse effects and should be used with caution 6, 5