What medication is prescribed for hyperkalemia (elevated potassium level)?

Management of Severe Hyperkalemia (6.7 mmol/L)

For a potassium level of 6.7 mmol/L, immediate intervention is required as this constitutes severe hyperkalemia requiring emergency treatment to prevent life-threatening cardiac arrhythmias. 1

Immediate Management

• Administer intravenous calcium (calcium chloride or calcium gluconate) for cardiac membrane stabilization to prevent arrhythmias 2, 3
• Use insulin plus glucose and/or nebulized beta-2 agonists to shift potassium into cells within 30-60 minutes 2, 4
• Consider sodium bicarbonate for additional intracellular potassium shifting, particularly in patients with metabolic acidosis 2, 5
• Initiate potassium elimination strategies (diuretics, potassium binders) 2, 4

Hospital Admission Criteria

• Severe hyperkalemia (>6.0 mEq/L) requires hospital admission regardless of symptoms due to high risk of cardiac arrhythmias and sudden death 2
• Any hyperkalemia with ECG changes (peaked T waves, flattened P waves, prolonged PR interval, widened QRS complex) requires immediate hospital care 2, 3
• Patients with high-risk comorbidities such as advanced chronic kidney disease, heart failure, or diabetes mellitus should be admitted for close monitoring 2

Medication Options for Potassium Elimination

Newer Potassium Binders

• Patiromer (Veltassa): FDA-approved for hyperkalemia treatment in adults and pediatric patients 12 years and older 6
  • Starting dose: 8.4 grams orally once daily for adults
  • Adjust dose by 8.4 grams daily at one-week intervals to reach desired potassium level
  • Maximum dose: 25.2 grams once daily
  • Important limitation: Not for emergency treatment due to delayed onset of action 6

Traditional Potassium Binders

• Sodium polystyrene sulfonate: FDA-approved for hyperkalemia treatment 7
  • Oral dosing: 15-60g daily, administered as 15g doses one to four times daily
  • Rectal dosing: 30-50g every six hours
  • Important limitations:
    • Not for emergency treatment due to delayed onset of action 7
    • Associated with serious gastrointestinal adverse effects including intestinal necrosis 7, 4
    • Should not be used with sorbitol due to increased risk of intestinal necrosis 7

Medication Management Considerations

• Evaluate and discontinue medications that may contribute to hyperkalemia, particularly mineralocorticoid receptor antagonists (MRAs) when potassium exceeds 6.0 mmol/L 8, 1
• For patients on renin-angiotensin-aldosterone system inhibitors (RAASi), temporary discontinuation is recommended at this potassium level 1, 9
• Take other orally administered drugs at least 3 hours before or 3 hours after potassium binders 6, 7

Monitoring and Follow-up

• Monitor ECG for cardiac conduction disturbances 2, 3
• Recheck potassium levels frequently until normalized 1
• Once stabilized, implement regular monitoring of potassium levels, especially after medication changes 2
• Monitor for hypomagnesemia when using patiromer 6

Long-term Management

• After acute management, identify and address the underlying cause of hyperkalemia 4
• Consider dietary potassium restriction 1
• Aim to maintain potassium levels ≤5.0 mmol/L, as levels above this threshold are associated with increased mortality risk, especially in patients with comorbidities 1, 10
• When restarting RAASi therapy, consider using newer potassium binders to enable continued use of these beneficial medications 9

Common Pitfalls to Avoid

• Delaying treatment of severe hyperkalemia while waiting for confirmation of repeat laboratory values 2
• Failing to rule out pseudohyperkalemia (falsely elevated potassium due to hemolysis during blood collection) 2
• Permanently discontinuing beneficial RAASi medications instead of considering dose reduction and addition of potassium binders 2, 9
• Using sodium polystyrene sulfonate for chronic hyperkalemia management due to its potential adverse effects 7, 4