What is the treatment for hyperkalemia?

Treatment of Hyperkalemia

The treatment of hyperkalemia requires a stepped approach starting with cardiac membrane stabilization using intravenous calcium, followed by measures to shift potassium into cells, and finally methods to eliminate potassium from the body. 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 1, 2
• Symptoms may be nonspecific, making laboratory confirmation and ECG assessment crucial 1

Acute Hyperkalemia Management

Step 1: Cardiac Membrane Stabilization (Immediate Effect)

• 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
• Calcium chloride provides more rapid increase in ionized calcium than calcium gluconate, making it more effective in critically ill patients 2
• Effects begin within 1-3 minutes but are temporary (30-60 minutes) and do not reduce serum potassium 1, 2

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

• Administer insulin with glucose: 10 units regular insulin IV with 25g glucose (50 mL of D50W) over 15-30 minutes 1, 2
• Consider nebulized albuterol: 10-20 mg over 15 minutes 1, 2
• For patients with concurrent metabolic acidosis, administer sodium bicarbonate: 50 mEq IV over 5 minutes 1, 2
• Effects of these interventions begin within 15-30 minutes and last 4-6 hours 1, 2

Step 3: Eliminate Potassium from Body (Longer-term Effect)

• Administer loop diuretics (furosemide 40-80 mg IV) in patients with adequate kidney function 1, 2
• Consider potassium binders such as sodium polystyrene sulfonate (15-60g orally or 30-50g rectally) 2, 3
• Hemodialysis is the most effective method for severe hyperkalemia, especially in patients with renal failure 1, 2

Important Clinical Considerations

• Temporary measures (insulin/glucose, albuterol) provide only transient effects (1-4 hours), and rebound hyperkalemia can occur after 2 hours 2
• Sodium polystyrene sulfonate should not be used for emergency treatment of life-threatening hyperkalemia due to its delayed onset of action 3
• Administer sodium polystyrene sulfonate at least 3 hours before or 3 hours after other oral medications (6 hours for patients with gastroparesis) 3
• Avoid concomitant administration of sorbitol with sodium polystyrene sulfonate due to risk of intestinal necrosis 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 1, 4
• Consider newer potassium binders (patiromer and sodium zirconium cyclosilicate) for long-term management 1, 4
• For patients on RAAS inhibitors with hyperkalemia >5.0 mEq/L, initiate a potassium-lowering agent and maintain RAAS inhibitor therapy unless alternative treatable etiology is identified 2

Special Populations

• Patients with cardiovascular disease on RAAS inhibitors require careful monitoring of potassium levels, with assessment 7-10 days after starting or increasing doses 1
• Patients with chronic kidney disease, heart failure, or diabetes are at higher risk for hyperkalemia and require more frequent monitoring 1
• A team approach for chronic hyperkalemia management is optimal 1, 4