What is the treatment for hyperkalemia?

Treatment for Hyperkalemia

The treatment of hyperkalemia requires a stepwise approach based on severity, with immediate cardiac membrane stabilization using IV calcium for severe cases (≥6.5 mEq/L) or those with ECG changes, followed by insulin with glucose and beta-agonists to shift potassium intracellularly, and finally elimination of potassium from the body using diuretics, potassium binders, or hemodialysis. 1, 2

Classification of Hyperkalemia

• Mild hyperkalemia: 5.0-5.9 mEq/L 1, 2
• Moderate hyperkalemia: 6.0-6.4 mEq/L 1, 2
• Severe hyperkalemia: ≥6.5 mEq/L (life-threatening) 1
• ECG changes (peaked T waves, flattened P waves, prolonged PR interval, widened QRS) indicate urgent treatment regardless of potassium level 1, 2

Step 1: Cardiac Membrane Stabilization (for Severe Hyperkalemia or ECG Changes)

• Administer intravenous calcium to protect the heart:
  • Calcium chloride (10%): 5-10 mL (500-1000 mg) IV over 2-5 minutes 1
  • OR Calcium gluconate (10%): 15-30 mL IV over 2-5 minutes 1, 3
• Effects begin within minutes but are temporary (30-60 minutes) 1, 2
• Note: Calcium administration does not lower serum potassium but protects against arrhythmias 1
• Avoid calcium in patients taking digoxin as it may potentiate digoxin toxicity 3

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 1, 3
  • Onset within 15-30 minutes, effect lasts 4-6 hours 1, 4
  • For pediatric patients: 0.1 unit/kg insulin with 400 mg/kg glucose 3
• Nebulized albuterol: 10-20 mg over 15 minutes 1, 5
• Consider sodium bicarbonate (50 mEq IV over 5 minutes) if concurrent metabolic acidosis is present 1, 2
• Normal saline (0.9% NaCl) can be used to improve renal perfusion 3

Step 3: Eliminate Potassium from Body

• Loop diuretics (e.g., furosemide 40-80 mg IV) for patients with adequate renal function 1, 2
• Potassium binders:
  • Sodium polystyrene sulfonate (Kayexalate): 15-50 g orally or rectally 1
  • Note: Not for emergency treatment of life-threatening hyperkalemia due to delayed onset of action 6
  • Newer potassium binders (patiromer and sodium zirconium cyclosilicate) are safer alternatives for chronic management 1, 2
• Hemodialysis for severe hyperkalemia, especially in patients with renal failure 1, 2

Monitoring During Treatment

• Check serum potassium levels at 1-2 hour intervals during acute treatment 3
• Monitor blood glucose frequently to prevent hypoglycemia when using insulin 3
• Observe for ECG changes indicating improvement or worsening 3
• Watch for rebound hyperkalemia 2-4 hours after treatment 3, 7

Management of Chronic or Recurrent Hyperkalemia

• Review and adjust medications that may contribute to hyperkalemia (ACE inhibitors, ARBs, MRAs, NSAIDs, beta-blockers) 1, 2
• For patients on RAAS inhibitors with hyperkalemia >5.0 mEq/L:
  • Initiate an approved potassium-lowering agent 8
  • Closely monitor potassium levels 8
  • Maintain RAAS inhibitor therapy unless alternative treatable etiology is identified 8
• For severe hyperkalemia (>6.5 mEq/L) in patients on RAAS inhibitors:
  • Discontinue/reduce RAAS inhibitor 8
  • Initiate potassium-lowering agent when levels >5.0 mEq/L 8
  • Monitor potassium levels closely 8

Common Pitfalls and Caveats

• Temporary measures (insulin/glucose, albuterol) provide only transient effects (1-4 hours) 1, 3
• Rebound hyperkalemia can occur after 2 hours, requiring close monitoring 1
• Sodium polystyrene sulfonate is not effective for emergency treatment 6, 5
• Normal saline alone is insufficient for treating significant hyperkalemia 3
• Avoid potassium-containing fluids such as Lactated Ringer's 3