What insulin should be administered for hyperkalemia?

From the Guidelines

Regular insulin is the recommended insulin to administer for hyperkalemia, given intravenously along with glucose to prevent hypoglycemia, as it effectively drives potassium into cells and lowers serum potassium levels within 15-30 minutes 1. When managing hyperkalemia, it is crucial to consider the severity of the condition and the presence of any electrocardiographic changes or muscle weakness.

• The treatment goals are to reduce serum potassium concentrations, counteract the cardiac and muscular effects of hyperkalemia, and address the underlying cause of the condition.
• Regular insulin, typically administered in a dose of 10 units intravenously, is effective in promoting the redistribution of potassium into the intracellular space, thereby lowering serum potassium levels 1.
• It is essential to administer glucose, usually 25 grams (as 50 mL of 50% dextrose solution), concurrently with insulin to prevent hypoglycemia, as insulin also drives glucose into cells.
• The effects of insulin and glucose on potassium levels are generally observed within 15-30 minutes and can last for several hours, making it a useful temporary treatment for hyperkalemia.
• Monitoring blood glucose after administration is necessary to ensure that hypoglycemia does not develop, and identifying and addressing the underlying cause of hyperkalemia is critical for effective management.

From the Research

Insulin Administration for Hyperkalemia

• The use of insulin in the management of hyperkalemia is a common practice, as it helps to shift potassium from the extracellular to the intracellular space 2, 3, 4, 5, 6.
• According to a study published in 2018, beta-agonists and intravenous insulin should be given to patients with hyperkalemia, and some experts recommend the use of synthetic short-acting insulins rather than regular insulin 2.
• A 2019 review suggests that insulin and dextrose are frequently used to manage patients with hyperkalemia, but hypoglycemia after insulin use is a frequent complication during hyperkalemia management 3.
• A 2022 study compared the effects of 5 units and 10 units of intravenous insulin on hyperkalemia in intensive care unit patients with renal insufficiency, and found that a lower dose of IV insulin does not result in lower statistically significant rates of hypoglycaemia, but provides a similar potassium-lowering effect and causes a meaningful decrease in hypoglycaemic episodes 4.
• The choice of insulin type and dose may depend on various factors, including the patient's glucose level, renal function, and body weight 3, 4.
• It is recommended to administer dextrose with insulin to prevent hypoglycemia, and to monitor the patient's glucose level hourly for at least 4-6 hours after administration 3.

Recommended Insulin Dose

• A study published in 2022 suggests that 5 units of IV insulin may be a suitable dose for the treatment of hyperkalemia in critically ill patients, as it provides a similar potassium-lowering effect to 10 units with a lower risk of hypoglycaemia 4.
• Another study published in 1990 found that intravenous insulin with glucose was effective in lowering plasma potassium in hemodialysis patients, but the optimal dose was not specified 5.
• The 2015 Cochrane review found that insulin-dextrose was effective in reducing serum potassium, but the optimal dose and type of insulin were not specified 6.

Combination Therapy

• A 1990 study found that the combination of insulin with glucose and albuterol was effective in lowering plasma potassium in hemodialysis patients, and that the hypoglycemic effect of insulin was attenuated by coadministration of albuterol 5.
• The 2015 Cochrane review found that salbutamol via any route and IV insulin-dextrose appear to be most effective at reducing serum potassium, but the optimal combination and dose of these therapies were not specified 6.