What is the treatment for hyperkalemia?

Treatment for Hyperkalemia

The treatment for hyperkalemia follows a stepwise approach based on severity, with immediate cardiac membrane stabilization using intravenous calcium, followed by shifting potassium into cells with insulin/glucose and beta-agonists, and ultimately eliminating potassium from the body through diuretics, potassium binders, or hemodialysis. 1, 2

Assessment of Severity

• 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, 2
• ECG changes (peaked T waves, flattened P waves, prolonged PR interval, widened QRS) indicate urgent treatment regardless of potassium level 1, 2
• Severe hyperkalemia (≥6.5 mEq/L) is life-threatening and requires immediate intervention 1

Step 1: Cardiac Membrane Stabilization (Immediate Effect)

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

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
  • Onset within 15-30 minutes, effect lasts 4-6 hours 1
  • Monitor blood glucose frequently to prevent hypoglycemia 3
• Nebulized beta-2 agonists:
  • Albuterol: 10-20 mg nebulized over 15 minutes 1
  • Onset within 15-30 minutes, effect lasts 4-6 hours 1
• Sodium bicarbonate:
  • 50 mEq IV over 5 minutes 1
  • Most effective in patients with concurrent metabolic acidosis 1, 2

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

• Loop diuretics (for patients with adequate renal function):
  • Furosemide: 40-80 mg IV 1
• Potassium binders:
  • Traditional: Sodium polystyrene sulfonate (Kayexalate): 15-50 g orally or rectally 1, 4
  • Newer agents: Patiromer or sodium zirconium cyclosilicate 1, 5
  • Note: Potassium binders should not be used as emergency treatment for life-threatening hyperkalemia due to delayed onset of action 5, 4
• Hemodialysis:
  • Most effective method for severe hyperkalemia, especially in patients with renal failure 1, 6
  • Consider when conventional therapies fail 6

IV Fluid Management

• Normal saline (0.9% NaCl) is the first-line IV fluid for acute hyperkalemia 3
• Avoid potassium-containing fluids such as Lactated Ringer's 3
• IV fluids alone are insufficient for treating significant hyperkalemia and must be combined with other potassium-lowering strategies 3

Monitoring During Treatment

• Check serum potassium levels at 1-2 hour intervals during acute treatment 3
• Monitor ECG for improvement or worsening 3
• Watch for rebound hyperkalemia 2-4 hours after treatment 1, 3

Important Clinical Considerations

• Temporary measures (insulin/glucose, albuterol) provide only transient effects (1-4 hours) 1
• Rebound hyperkalemia can occur after 2 hours 1
• Review and adjust medications that may contribute to hyperkalemia (ACE inhibitors, ARBs, MRAs, NSAIDs, beta-blockers) 1, 2
• For chronic hyperkalemia management, consider newer potassium binders like patiromer 5, 7

Special Populations

• Pediatric dosing:
  • Calcium chloride: 20 mg/kg (0.2 mL/kg for 10% CaCl₂) 1
  • Insulin: 0.1 unit/kg with 400 mg/kg glucose 3
• Patients with malignant hyperthermia: Use calcium only in extreme cases as it may contribute to calcium overload 2