What is the treatment for hyperkalemia?

Treatment of Hyperkalemia

The treatment of hyperkalemia requires a stepwise approach consisting of cardiac membrane stabilization, intracellular potassium shifting, and total body potassium reduction, with immediate interventions determined by the severity and associated ECG changes. 1

Immediate Treatment for Severe/Life-Threatening Hyperkalemia

Step 1: Cardiac Membrane Stabilization

• Calcium Gluconate 10%: 10-15 mL IV over 5-10 minutes 1, 2
  • Onset: 1-3 minutes; Duration: 30-60 minutes
  • Protects heart from arrhythmias but does not lower potassium levels
  • Most effective for main rhythm disorders on ECG 2
  • For cardiac arrest, calcium chloride is preferred 3

Step 2: Shift Potassium Intracellularly

• Insulin with Glucose:

  • 10 units regular insulin IV with 50 mL of 25% dextrose (50g) 1, 4
  • Alternative for severe hyperkalemia (>6.5 mmol/L): 20 units as continuous infusion over 60 minutes with 60g glucose 4
  • Onset: 15-30 minutes; Duration: 1-2 hours
  • Monitor glucose levels to prevent hypoglycemia (occurs in ~20% of patients) 4

• Additional Shifting Options:

  • Inhaled beta-agonists: 10-20 mg albuterol nebulized over 15 minutes 1, 5
    • Can be combined with insulin for additive effect 5
    • Onset: 15-30 minutes; Duration: 2-4 hours
  • Sodium bicarbonate: 50 mEq IV over 5 minutes (if metabolic acidosis present) 1
    • Onset: 15-30 minutes; Duration: 1-2 hours

Step 3: Remove Potassium from Body

• Diuretics: IV furosemide if renal function permits 1, 5
• Hemodialysis: Most efficient method for potassium removal in severe cases 3, 5

Treatment for Non-Emergency Hyperkalemia

Potassium Binders

• Patiromer (Veltassa):

  • Starting dose: 8.4g once daily 1
  • Onset: 7 hours
  • Separate from other medications by 3 hours
  • No sodium content

• Sodium zirconium cyclosilicate (Lokelma):

  • Dose: 5-10g once daily 1
  • Onset: 1 hour (faster than patiromer)
  • Contains sodium (400mg per 5g)

• Sodium polystyrene sulfonate:

  • Dose: 15-60g daily, divided into 1-4 doses 1, 6
  • Important limitation: Not for emergency treatment of life-threatening hyperkalemia due to delayed onset 6
  • Administration:
    • Oral: Suspend in 3-4 mL of water or syrup per gram of resin 6
    • Rectal: 30-50g every 6 hours as enema 6
  • Administer at least 3 hours before or after other oral medications 6
  • Caution: Risk of intestinal necrosis, especially with sorbitol; avoid in patients with bowel obstruction or reduced gut motility 6

Monitoring and Follow-up

• Serial ECGs to monitor cardiac changes 1
• Continuous cardiac monitoring for moderate to severe hyperkalemia 1
• Regular serum potassium measurements 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

Long-term Management

• Dietary potassium restriction (<40 mg/kg/day) 1, 7
• Avoid high-potassium foods: processed foods, bananas, oranges, potatoes, tomatoes, legumes 1
• Review and adjust medications that may contribute to hyperkalemia 7
• For patients with CKD stage 4, consider nephrology referral 1
• Maintain renin-angiotensin-aldosterone inhibitors if possible, as they improve outcomes in heart failure and proteinuric kidney disease 7

Common Pitfalls and Caveats

• Absence of ECG changes does not exclude the need for immediate intervention in severe hyperkalemia 5
• Sodium polystyrene sulfonate should not be used for emergency treatment due to delayed onset 6
• Hypoglycemia is a common complication of insulin therapy; ensure adequate glucose administration and monitoring 4
• Avoid sorbitol with sodium polystyrene sulfonate due to risk of intestinal necrosis 6
• Chronic hyperkalemia requires addressing underlying causes rather than just symptomatic treatment 7