What is the medical management of hyperkalemia?

Medical Management of Hyperkalemia

The management of hyperkalemia requires a systematic approach starting with calcium gluconate administration for cardiac membrane stabilization, followed by insulin with glucose and beta-agonists to shift potassium intracellularly, and ultimately removing excess potassium from the body through diuretics, potassium binders, or dialysis. 1, 2

Acute Hyperkalemia Management

Step 1: Cardiac Membrane Stabilization (Immediate)

• Administer intravenous calcium gluconate (10%): 15-30 mL IV over 2-5 minutes to stabilize cardiac membranes and prevent arrhythmias 1, 2, 3
• Effects begin within 1-3 minutes but are temporary (30-60 minutes) and do not reduce serum potassium levels 1, 2
• If no effect is observed within 5-10 minutes, another dose of calcium gluconate may be given 1

Step 2: Shift Potassium into Cells (15-30 minutes)

• Administer insulin with glucose: 10 units regular insulin with 25g glucose IV over 15-30 minutes 1, 2, 4
• Nebulized beta-agonists (e.g., albuterol 10-20 mg) can be used alone or in combination with insulin/glucose 2, 4
• Consider sodium bicarbonate (50 mEq IV) only in patients with concurrent metabolic acidosis 1, 2
• These interventions begin working within 15-30 minutes and last 4-6 hours 5, 2

Step 3: Remove Potassium from Body (Hours)

• Administer loop diuretics (e.g., furosemide 40-80 mg IV) in patients with adequate kidney function 2, 6
• Consider potassium binders such as sodium polystyrene sulfonate (SPS), patiromer, or sodium zirconium cyclosilicate 2, 7
• Hemodialysis is the most effective method for severe hyperkalemia, especially in patients with renal failure 1, 2, 8

Chronic Hyperkalemia Management

• Review and adjust medications that may contribute to hyperkalemia (ACE inhibitors, ARBs, NSAIDs, etc.) 2, 9
• Prescribe loop or thiazide diuretics to promote urinary potassium excretion 1, 2
• Consider newer FDA-approved potassium binders (patiromer, sodium zirconium cyclosilicate) for long-term management 5, 2
• Note that sodium polystyrene sulfonate (Kayexalate) is not recommended for emergency treatment due to its delayed onset of action 7, 4

Special Considerations

• ECG changes such as peaked T waves, flattened P waves, prolonged PR interval, and widened QRS complex indicate urgent treatment regardless of potassium level 2, 3
• Calcium should not be administered through the same line as sodium bicarbonate 3
• Patients with chronic kidney disease, heart failure, or diabetes require more frequent monitoring of potassium levels 2, 9
• A team approach involving specialists (cardiologists, nephrologists), primary care physicians, and other healthcare professionals is optimal for chronic hyperkalemia management 1, 2

Treatment Algorithm Based on Severity

• Mild hyperkalemia (5.0-5.9 mEq/L): Dietary modification, medication review, and potassium binders if persistent 2
• Moderate hyperkalemia (6.0-6.4 mEq/L): Consider insulin/glucose, beta-agonists, and potassium binders 2, 10
• Severe hyperkalemia (≥6.5 mEq/L) or with ECG changes: Immediate calcium administration followed by insulin/glucose, beta-agonists, and consider hemodialysis 2, 3, 8

Common Pitfalls to Avoid

• Relying solely on ECG findings, which can be variable and less sensitive than laboratory tests 1
• Using sodium bicarbonate as monotherapy, which has poor efficacy as a potassium-lowering agent 10
• Delaying hemodialysis in severe cases unresponsive to medical management 8
• Discontinuing beneficial RAAS inhibitors without trying potassium binders first in chronic hyperkalemia 9