What is the treatment for hyperkalemia?

Hyperkalemia Treatment

The treatment of hyperkalemia requires a stepwise approach based on severity, with immediate calcium administration for cardiac stabilization, followed by insulin/glucose and beta-agonists to shift potassium into cells, and finally potassium elimination strategies including diuretics, binders, or dialysis. 1, 2

Classification and Assessment

• 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, and ECG findings can be variable and less sensitive than laboratory tests 1

Acute Hyperkalemia Management Algorithm

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 1, 2
• Effects begin within 1-3 minutes but are temporary (30-60 minutes) and do not reduce serum potassium 1
• Note: In patients with malignant hyperthermia, calcium should only be used in extremis 1

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
• Consider nebulized albuterol: 10-20 mg over 15 minutes 2, 3
• For patients with concurrent metabolic acidosis, administer sodium bicarbonate: 50 mEq IV over 5 minutes 1, 2
• Effects of insulin/glucose and beta-agonists begin within 15-30 minutes and last 4-6 hours 1, 2

Step 3: Eliminate Potassium from Body

• For patients with adequate kidney function, administer loop diuretics such as furosemide 40-80 mg IV 1, 2
• Consider potassium binders:
  • Traditional: Sodium polystyrene sulfonate (15-50g orally or rectally) 2
  • Newer agents: Patiromer or sodium zirconium cyclosilicate 1, 2
• Important: Sodium polystyrene sulfonate should not be used for emergency treatment of life-threatening hyperkalemia due to its delayed onset of action 4
• For severe or refractory hyperkalemia, especially in renal failure, hemodialysis is the most effective method 1, 2, 3

Chronic Hyperkalemia Management

• Review and adjust medications that may contribute to hyperkalemia (ACE inhibitors, ARBs, MRAs, NSAIDs, beta-blockers) 1, 2
• Use loop or thiazide diuretics to promote urinary potassium excretion in patients with adequate kidney function 1, 5
• Consider newer FDA-approved potassium binders (patiromer and sodium zirconium cyclosilicate) for long-term management 1, 5, 6
• For patients on RAAS inhibitors with hyperkalemia >5.0 mEq/L, initiate a potassium-lowering agent while maintaining RAAS inhibitor therapy unless alternative treatable etiology is identified 2

Clinical Pearls and Pitfalls

• Temporary measures (insulin/glucose, albuterol) provide only transient effects (1-4 hours), and rebound hyperkalemia can occur after 2 hours 2, 7
• Initiate potassium-lowering agents as early as possible to prevent rebound 2
• Monitor potassium levels closely during treatment to avoid overcorrection and hypokalemia 2
• Absent or atypical ECG changes do not exclude the necessity for immediate intervention in severe hyperkalemia 7
• Patients with chronic kidney disease, heart failure, or diabetes are at higher risk for hyperkalemia and require more frequent monitoring 1
• A team approach involving specialists and primary care physicians is optimal for chronic hyperkalemia management 1, 5