What is the treatment for hyperkalemia?

Treatment of Hyperkalemia

The treatment of hyperkalemia requires a stepwise approach based on severity, with immediate cardiac membrane stabilization using intravenous calcium for severe cases, followed by shifting potassium into cells with insulin/glucose and beta-agonists, and finally eliminating potassium from the body through diuretics, potassium binders, or dialysis. 1, 2

Assessment and Classification

• Hyperkalemia is classified as mild (5.0-5.9 mEq/L), moderate (6.0-6.4 mEq/L), or severe (≥6.5 mEq/L) 2
• ECG changes (peaked T waves, flattened P waves, prolonged PR interval, widened QRS) indicate urgent treatment regardless of potassium level 2
• Symptoms may be nonspecific, and ECG findings can be highly variable and less sensitive than laboratory tests 1

Acute Hyperkalemia Management

Step 1: Cardiac Membrane Stabilization

• Administer intravenous calcium gluconate (10%): 15-30 mL IV over 2-5 minutes, or calcium chloride (10%): 5-10 mL IV over 2-5 minutes 2
• Effects begin within 1-3 minutes but are temporary (30-60 minutes) and do not reduce serum potassium 1, 2
• If no effect is observed within 5-10 minutes, another dose of calcium may be given 1

Step 2: Shift Potassium into Cells

• Administer 10 units regular insulin IV with 25g glucose (50 mL of D50W) over 15-30 minutes 2
• Onset of action is within 15-30 minutes, with effects lasting 4-6 hours 2
• Nebulized beta-2 agonists (albuterol 10-20 mg over 15 minutes) can be used alone or in combination with insulin/glucose 2
• Sodium bicarbonate (50 mEq IV over 5 minutes) is most effective in patients with concurrent metabolic acidosis 2

Step 3: Eliminate Potassium from Body

• Loop diuretics (furosemide 40-80 mg IV) can increase renal potassium excretion in patients with adequate kidney function 2
• Hemodialysis is the most effective method for severe hyperkalemia, especially in patients with renal failure 2
• Cation exchange resins (sodium polystyrene sulfonate 15-50g orally or rectally) can be used, but are not for emergency treatment due to delayed onset of action 3
• Newer potassium binders (patiromer, sodium zirconium cyclosilicate) are safer alternatives to traditional resins 2

Important Clinical Considerations

• Temporary measures (insulin/glucose, albuterol) provide only transient effects (1-4 hours), and rebound hyperkalemia can occur after 2 hours 1, 2
• Treatment with potassium-lowering agents should be initiated as early as possible to prevent rebound 2
• Monitor potassium levels closely during treatment to avoid overcorrection and hypokalaemia 2

Chronic Hyperkalemia Management

• Review and adjust medications that may contribute to hyperkalemia (ACE inhibitors, ARBs, MRAs, NSAIDs, beta-blockers) 2
• Use loop or thiazide diuretics to promote urinary excretion of potassium 1
• Consider newer FDA-approved potassium binders for long-term management 1
• Fludrocortisone can increase potassium excretion in patients with aldosterone deficiency but carries risks of fluid retention, hypertension, and vascular injury 1

Special Considerations

• In patients with cardiovascular disease on RAAS inhibitors, careful monitoring of potassium levels is essential, with assessment 7-10 days after starting or increasing doses 1
• Patients with chronic kidney disease, heart failure, or diabetes are at higher risk for hyperkalemia and require more frequent monitoring 1
• A team approach for chronic hyperkalemia management is optimal, involving specialists, primary care physicians, and other healthcare professionals 1