How to prescribe treatment for hyperkalemia?

Treatment Algorithm for Hyperkalemia

For effective management of hyperkalemia, newer potassium binders should be used preferentially over sodium polystyrene sulfonate due to their superior safety profiles and more predictable effects on serum potassium levels. 1

Initial Assessment and Treatment Based on Severity

Severe Hyperkalemia (K+ >6.5 mEq/L)

• Discontinue or reduce RAASi therapy immediately 1
• Initiate emergency measures first (calcium, insulin/glucose, nebulized albuterol) due to their rapid onset of action 2
• After stabilization, initiate a potassium-lowering agent when K+ >5.0 mEq/L 1
• Monitor K+ levels closely throughout treatment 1

Moderate Hyperkalemia (K+ 5.0-6.5 mEq/L)

• For patients on RAASi therapy: initiate a potassium-lowering agent while maintaining RAASi if possible 1
• For patients not on maximal RAASi therapy: initiate a potassium-lowering agent first, then up-titrate RAASi when K+ <5.0 mEq/L 1
• Monitor K+ levels closely throughout treatment 1

Mild Hyperkalemia (K+ 4.5-5.0 mEq/L)

• For patients not on maximal RAASi therapy: up-titrate RAASi and monitor K+ levels 1
• If K+ rises above 5.0 mEq/L, initiate a potassium-lowering agent 1

Medication Selection and Dosing

Preferred Agents for Chronic Hyperkalemia Management

Sodium Zirconium Cyclosilicate (Lokelma)

• Initial treatment: 10 g three times daily for up to 48 hours 3
• Maintenance: 5-15 g once daily, adjusted based on serum K+ levels 3
• For hemodialysis patients: administer only on non-dialysis days, starting at 5 g once daily (10 g for K+ >6.5 mEq/L) 3
• Administer as suspension in water; other oral medications should be taken at least 2 hours before or after 3

Patiromer

• Effective for both mild and moderate hyperkalemia 1
• Dosing: 4.2-16.8 g BID based on severity of hyperkalemia 1
• Particularly beneficial in patients with heart failure or CKD on RAASi therapy 1

Alternative Agent (Use with Caution)

Sodium Polystyrene Sulfonate (SPS)

• Not recommended for emergency treatment due to delayed onset of action (hours to days) 4
• Oral dosing: 15-60 g daily, administered as 15 g one to four times daily 4
• Rectal dosing: 30-50 g every six hours (for patients unable to take oral medication) 4
• Administer at least 3 hours before or after other oral medications (6 hours for patients with gastroparesis) 4
• Important safety concerns: Associated with serious gastrointestinal adverse events including intestinal necrosis (especially when used with sorbitol), bleeding, and perforation 4
• Contraindicated in patients with obstructive bowel disease or reduced gut motility 4

Monitoring and Follow-up

• Monitor serum K+ regularly during treatment and adjust dosing accordingly 1
• For SPS, also monitor calcium and magnesium levels due to non-selective binding 2
• For patients on RAASi therapy, continue monitoring K+ levels to maintain optimal RAASi dosing 1

Additional Measures for Hyperkalemia Management

• Initiate or increase non-K+-sparing diuretics 1
• Implement low K+ diet 1
• Eliminate K+ supplements 1
• Discontinue medications that compromise renal function (e.g., NSAIDs) 1

Important Considerations and Pitfalls

• SPS has never undergone rigorous testing in placebo-controlled trials for hyperkalemia treatment, and its efficacy is inconsistent 1
• SPS can cause significant electrolyte disturbances including hypokalemia, hypocalcemia, and hypomagnesemia 2
• SPS may increase sodium load, which is problematic for patients with heart failure, severe hypertension, or marked edema 1
• Clinical studies show SPS reduces serum K+ by only 0.14-1.04 mEq/L, which may not be clinically significant for all patients 5, 6
• Higher doses of SPS (60g) are more effective than lower doses (15g) for achieving normokalemia, but carry increased risk of adverse effects 7