What is the treatment for hyperkalemia?

Treatment of Hyperkalemia

The treatment of hyperkalemia should follow a stepwise approach based on severity, with immediate administration of calcium gluconate for severe hyperkalemia (≥6.0 mEq/L) with ECG changes, followed by insulin with glucose and beta-agonists to shift potassium intracellularly, and potassium-binding agents for definitive removal. 1

Classification of Hyperkalemia

• Mild: 5.0-5.5 mEq/L
• Moderate: 5.6-5.9 mEq/L
• Severe: ≥6.0 mEq/L 1

Emergency Treatment for Severe Hyperkalemia

For severe hyperkalemia (≥6.0 mEq/L) or presence of ECG changes:

1. Cardiac Membrane Stabilization:

   • Calcium gluconate 10% solution, 15-30 mL IV (onset: 1-3 minutes, duration: 30-60 minutes) 1
   • Indicated when ECG changes are present, even if potassium levels aren't severely elevated

2. Intracellular Shift of Potassium:

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

Potassium Removal from Body

1. Diuretics:

   • IV furosemide if renal function permits 1

2. Potassium-binding Agents:

   • Patiromer (Veltassa): 8.4g once daily (onset: 7 hours) - separate from other medications by 3 hours 1
   • Sodium zirconium cyclosilicate (Lokelma): 5-10g once daily (onset: 1 hour) - contains sodium (400mg per 5g) 1
   • Sodium polystyrene sulfonate: 15-30g 1-4 times daily (oral or rectal) 1, 3
     • Important caveat: Not for emergency treatment due to delayed onset of action 3
     • Dosage: Oral: 15-60g daily divided into 1-4 doses; Rectal: 30-50g every 6 hours 3

3. Hemodialysis:

   • Most rapid and effective method for severe cases, especially in patients with kidney failure 2, 4

Medication Management

• Discontinue medications that can worsen hyperkalemia:
  • ACE inhibitors
  • ARBs
  • Potassium-sparing diuretics
  • NSAIDs
  • Potassium supplements 1

Cardiac Monitoring

Monitor ECG for changes related to potassium levels:

• 5.5-6.5 mmol/L: Peaked/tented T waves (early sign)
• 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

Dietary Modifications

• Limit potassium intake to <40 mg/kg/day
• Avoid high-potassium foods: processed foods, bananas, oranges, potatoes, tomatoes, legumes, yogurt, and chocolate 1

Treatment Algorithm Based on Severity

Mild Hyperkalemia (5.0-5.5 mEq/L):

1. Review and adjust medications
2. Dietary potassium restriction
3. Consider potassium-binding agents if persistent

Moderate Hyperkalemia (5.6-5.9 mEq/L):

1. Review and adjust medications
2. Dietary potassium restriction
3. Potassium-binding agents
4. Consider loop diuretics if renal function permits

Severe Hyperkalemia (≥6.0 mEq/L) or with ECG changes:

1. Calcium gluconate IV immediately
2. Insulin with glucose IV ± nebulized beta-agonists
3. Consider sodium bicarbonate if acidotic
4. Potassium-binding agents
5. Loop diuretics if renal function permits
6. Consider hemodialysis in refractory cases or severe renal dysfunction

Common Pitfalls and Caveats

• Do not rely solely on ECG changes to guide treatment decisions, as they may be absent despite dangerous potassium levels 2
• Sodium polystyrene sulfonate should not be used for emergency treatment due to its delayed onset of action 3
• Monitor for rebound hyperkalemia after temporary shifting treatments wear off 5
• Avoid concomitant use of sodium polystyrene sulfonate with sorbitol due to risk of intestinal necrosis 3
• Separate sodium polystyrene sulfonate from other oral medications by at least 3 hours to prevent drug interactions 3
• Monitor for hypokalemia during aggressive treatment, especially with insulin/glucose and beta-agonists
• Be aware of sodium content in sodium-containing binding agents in patients with heart failure or hypertension 1