What is the treatment for hyperkalemia?

Treatment of Hyperkalemia

The treatment of hyperkalemia requires a stepwise approach based on severity, with immediate calcium administration for cardiac stabilization in severe cases, followed by insulin with glucose and beta-agonists to shift potassium intracellularly, and finally methods to eliminate potassium from the body through diuretics, potassium binders, or hemodialysis. 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) 1
• ECG changes (peaked T waves, flattened P waves, prolonged PR interval, widened QRS) indicate urgent treatment regardless of potassium level 1, 2
• Treatment approach should be guided by severity, presence of ECG changes, and symptoms 2

Step 1: Cardiac Membrane Stabilization (For Severe or Symptomatic Hyperkalemia)

• Administer intravenous calcium to protect the heart:
  • 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
• This step is critical for preventing life-threatening arrhythmias while other treatments take effect 2

Step 2: Shift Potassium into Cells

• Insulin with glucose: 10 units regular insulin IV with 25g glucose (50 mL of D50W) over 15-30 minutes 2
  • Onset within 15-30 minutes, effects last 4-6 hours 1, 2
• Nebulized albuterol: 10-20 mg over 15 minutes 2
  • Can be used alone or in combination with insulin/glucose for additive effect 3
• Sodium bicarbonate: 50 mEq IV over 5 minutes (most effective in patients with concurrent metabolic acidosis) 2

Step 3: Eliminate Potassium from Body

• Loop diuretics: Furosemide 40-80 mg IV (effective only in patients with adequate renal function) 1, 2
• Potassium binders:
  • Newer agents: Patiromer and sodium zirconium cyclosilicate for long-term management 1, 2
  • Sodium polystyrene sulfonate: 15-50 g orally or rectally 2
    • Important limitation: Not for emergency treatment of life-threatening hyperkalemia due to delayed onset of action 4
• Hemodialysis: Most effective method for severe hyperkalemia, especially in patients with renal failure 1, 2

Treatment Algorithm Based on Severity

Mild Hyperkalemia (5.0-5.9 mEq/L) without ECG Changes

• Review and adjust medications that may contribute to hyperkalemia 1
• Loop or thiazide diuretics if renal function is adequate 1
• Oral potassium binders for chronic management 1, 5

Moderate Hyperkalemia (6.0-6.4 mEq/L) or Mild with ECG Changes

• All measures for mild hyperkalemia
• Consider insulin/glucose and/or nebulized albuterol 2, 6
• More aggressive use of potassium elimination methods 7

Severe Hyperkalemia (≥6.5 mEq/L) or Any Level with Significant ECG Changes

• Immediate calcium administration for cardiac protection 2, 8
• Insulin/glucose AND nebulized albuterol 2, 3
• Urgent hemodialysis if available, especially with renal failure 1, 2

Important Clinical Considerations

• Monitor potassium levels frequently during treatment to assess response and detect rebound hyperkalemia 2, 5
• Temporary measures (insulin/glucose, albuterol) provide only transient effects; rebound can occur after 2 hours 2
• Identify and address underlying causes (renal failure, medications, acidosis) 7, 5
• Common medications contributing to hyperkalemia include ACE inhibitors, ARBs, MRAs, NSAIDs, and beta-blockers 1, 2
• Patients with chronic kidney disease, heart failure, or diabetes require more frequent monitoring due to higher risk 1