From the Guidelines
Managing hyperkalemia involves prompt identification and treatment based on severity, with the goal of reducing morbidity, mortality, and improving quality of life, and the most recent evidence suggests that individualized monitoring of serum potassium and the use of newer potassium-binding agents, such as patiromer sorbitex calcium and sodium zirconium cyclosilicate, may facilitate optimization of renin-angiotensin-aldosterone system inhibitor (RAASi) therapy 1.
Treatment Approach
For mild hyperkalemia (5.0-5.9 mmol/L), dietary potassium restriction and review of medications that can raise potassium levels are recommended.
- The medications that can raise potassium levels include:
- Potassium-sparing diuretics (e.g. spironolactone, triamterene, amiloride)
- Beta-blockers
- NSAIDs
- Sacubitril/valsartan
- Renin-angiotensin-aldosterone inhibitors (RAASi): ACE inhibitors, angiotensin receptor blockers, mineralocorticoid receptor antagonists (MRAs)
- Direct renin inhibitors (aliskiren)
- Mannitol
- Cyclosporine or tacrolimus
- Pentamidine
- Trimethoprim-sulfamethoxazole
- Heparin
- Digitalis
- Calcineurin inhibitors
- Penicillin G For moderate hyperkalemia (6.0-6.4 mmol/L), administer oral potassium binders like sodium polystyrene sulfonate (Kayexalate) 15-30g or patiromer 8.4g once daily, along with oral calcium resonium 15g three times daily.
Severe Hyperkalemia
For severe hyperkalemia (≥6.5 mmol/L) or when ECG changes are present, immediate treatment is necessary:
- Give IV calcium gluconate 10% 10-20mL over 2-3 minutes to stabilize cardiac membranes,
- Followed by IV insulin 10 units with 50mL of 50% glucose to shift potassium intracellularly.
- Nebulized salbutamol 10-20mg and IV sodium bicarbonate 50mmol may also help shift potassium into cells. Dialysis should be considered for refractory cases or in patients with renal failure.
Underlying Cause
The underlying cause of hyperkalemia must be addressed, which often involves adjusting medications like ACE inhibitors, ARBs, potassium-sparing diuretics, or NSAIDs. Regular monitoring of serum potassium levels is essential during treatment, and the frequency of monitoring should be individualized, with increased frequency considered for patients with chronic kidney disease, diabetes, heart failure, or a history of hyperkalemia, and for those receiving RAASi therapy 1. These interventions work by either removing potassium from the body, shifting it from extracellular to intracellular space, or protecting against cardiac effects while definitive treatment takes effect. The use of newer potassium-binding agents may allow for optimization of RAASi therapy and more effective management of hyperkalemia, as suggested by recent clinical studies 1.
From the FDA Drug Label
Sodium polystyrene sulfonate is a potassium binder indicated for the treatment of hyperkalemia Limitation of Use: Sodium polystyrene sulfonate should not be used an emergency treatment for life threatening hyperkalemia because of its delayed onset of action.
The management of hyperkalemia includes the use of sodium polystyrene sulfonate as a potassium binder for treatment. However, it is important to note that sodium polystyrene sulfonate should not be used as an emergency treatment for life-threatening hyperkalemia due to its delayed onset of action 2.
From the Research
Management Strategies
The management of hyperkalemia involves several strategies, including:
- Elimination of reversible causes (diet, medications) 3
- Rapidly acting therapies that shift potassium into cells and block the cardiac membrane effects of hyperkalemia 3, 4
- Measures to facilitate removal of potassium from the body (saline diuresis, oral binding resins, and hemodialysis) 3, 4, 5
Treatment Options
Treatment options for hyperkalemia include:
- Calcium gluconate to stabilize cardiomyocyte membranes 3, 4
- Insulin injection to shift potassium into cells 3, 4, 6, 5
- Beta-2 agonists administration to shift potassium into cells 3, 4, 5
- Hemodialysis to remove potassium from the body 3, 4, 5
- Oral binding resins, such as sodium polystyrene sulfonate, patiromer, and sodium zirconium cyclosilicate, to promote gastrointestinal potassium excretion 4, 6, 7
Medical Emergency
Hyperkalemia with potassium level more than 6.5 mEq/L or EKG changes is a medical emergency and should be treated accordingly 3
- Treatment should be started with calcium gluconate to stabilize cardiomyocyte membranes, followed by insulin injection, and beta-2 agonists administration 3, 4
Novel Therapies
New medications, such as patiromer and sodium zirconium cyclosilicate, hold promise in the management of hyperkalemia by promoting gastrointestinal potassium excretion 4, 6, 7