What is the treatment for hyperkalemia?

Treatment of Hyperkalemia

The treatment of hyperkalemia requires a stepwise approach starting with cardiac membrane stabilization using intravenous calcium, followed by potassium shifting into cells with insulin/glucose or beta-agonists, and finally eliminating 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 2
• Symptoms may be nonspecific, making laboratory confirmation and ECG assessment critical 1

Step 1: Cardiac Membrane Stabilization (for severe hyperkalemia or ECG changes)

• 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
• Calcium stabilizes cardiac membranes to prevent arrhythmias while definitive treatment takes effect 2

Step 2: Shift Potassium into Cells

• Administer insulin with glucose: 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 and effects last 4-6 hours 1, 2
• Nebulized albuterol (10-20 mg over 15 minutes) can be used as an adjunct or alternative 2
• Sodium bicarbonate (50 mEq IV over 5 minutes) is most effective in patients with concurrent metabolic acidosis 1, 2

Step 3: Eliminate Potassium from Body

• Loop diuretics (furosemide 40-80 mg IV) increase renal potassium excretion in patients with adequate kidney function 1, 2
• Potassium binders:
  • Sodium polystyrene sulfonate (15-50 g orally or rectally) can be used, but is not for emergency treatment due to delayed onset of action 3
  • Newer potassium binders (patiromer and sodium zirconium cyclosilicate) are safer alternatives for chronic management 1, 2
• Hemodialysis is the most effective method for severe hyperkalemia, especially in patients with renal failure 1, 2

Chronic Hyperkalemia Management

• Review and adjust medications that may contribute to hyperkalemia (ACE inhibitors, ARBs, MRAs, NSAIDs, beta-blockers) 1
• Use loop or thiazide diuretics to promote urinary excretion of potassium 1, 4
• Consider newer potassium binders for long-term management 1, 4
• Regular monitoring of serum potassium levels is essential, especially when starting new medications 4

Important Clinical Considerations

• Temporary measures (insulin/glucose, albuterol) provide only transient effects (1-4 hours), and rebound hyperkalemia can occur after 2 hours 2
• Treatment with potassium-lowering agents should be initiated early to prevent rebound 2
• Monitor potassium levels closely during treatment to avoid overcorrection and hypokalemia 2
• Sodium polystyrene sulfonate should not be used as an emergency treatment for life-threatening hyperkalemia due to its delayed onset of action 3
• For patients with chronic kidney disease, heart failure, or diabetes, more frequent monitoring is required due to higher risk for hyperkalemia 1

Treatment Algorithm Based on Severity

• Mild hyperkalemia (5.0-5.9 mEq/L) without ECG changes:

  • Review and adjust medications 1
  • Consider loop or thiazide diuretics if renal function permits 1
  • Consider oral potassium binders for chronic management 4

• Moderate hyperkalemia (6.0-6.4 mEq/L) or mild with ECG changes:

  • All treatments for mild hyperkalemia 1
  • Add insulin/glucose or nebulized albuterol 2
  • Consider sodium bicarbonate if metabolic acidosis is present 1

• Severe hyperkalemia (≥6.5 mEq/L) or moderate with ECG changes:

  • Immediate calcium administration for cardiac protection 2
  • Insulin/glucose and albuterol for potassium shifting 1, 2
  • Sodium bicarbonate if metabolic acidosis is present 1
  • Loop diuretics if renal function permits 1
  • Consider hemodialysis, especially with renal failure 2
  • Potassium binders for ongoing management 4