How to treat hyperkalemia (elevated serum potassium)?

From the Guidelines

Severe hyperkalemia requires immediate treatment with calcium gluconate to stabilize cardiac membranes, followed by measures to shift potassium intracellularly and eliminate it from the body. The most recent and highest quality study on the management of hyperkalemia is from 2021 1, which emphasizes the importance of rapid intervention in severe cases. To treat hyperkalemia, the following steps should be taken:

• Stabilize myocardial cell membrane with calcium chloride (10%): 5 to 10 mL (500 to 1000 mg) IV over 2 to 5 minutes or calcium gluconate (10%): 15 to 30 mL IV over 2 to 5 minutes, as recommended by the 2010 American Heart Association guidelines 1.
• Shift potassium into cells using sodium bicarbonate: 50 mEq IV over 5 minutes, as suggested by the 2010 American Heart Association guidelines 1.
• Eliminate potassium from the body using sodium polystyrene sulfonate (Kayexalate) 15-30g orally or rectally, or consider patiromer (Veltassa) 8.4g orally. Some key points to consider when treating hyperkalemia include:
• The risk of mortality, cardiovascular morbidity, progression of CKD, and hospitalization is increased in patients with hyperkalemia, especially those with CKD, HF, and diabetes 1.
• A U-shaped curve exists between serum K+ and mortality, with both hyperkalemia and hypokalemia associated with adverse clinical outcomes 1.
• The exact K+ concentration that clinicians should consider to be life-threatening remains controversial, and the optimal range for serum K+ concentrations varies according to individual patient comorbidities 1.
• In patients with CKD, compensatory mechanisms may result in tolerance to elevated circulating K+, and several studies have suggested that hyperkalemia is a less threatening condition in CKD 1. In severe cases with renal failure or persistent hyperkalemia, urgent hemodialysis may be necessary. It is also essential to identify and treat the underlying cause of hyperkalemia, which may include medication review (stop ACE inhibitors, ARBs, potassium-sparing diuretics), treating acidosis, or addressing renal dysfunction. Hyperkalemia is dangerous because excess extracellular potassium disrupts the normal membrane potential of cardiac cells, potentially causing arrhythmias and cardiac arrest, which is why rapid intervention is essential.

From the FDA Drug Label

In Part A, 243 patients were treated with Veltassa for 4 weeks. Patients with a baseline serum potassium of 5.1 mEq/L to < 5.5 mEq/L received a starting Veltassa dose of 8.4 grams patiromer per day (as a divided dose) and patients with a baseline serum potassium of 5.5 mEq/L to < 6. 5 mEq/L received a starting Veltassa dose of 16.8 grams patiromer per day (as a divided dose). The dose of Veltassa was titrated, as needed, based on the serum potassium level, assessed starting on Day 3 and then at weekly visits (Weeks 1,2 and 3) to the end of the 4-week treatment period, with the aim of maintaining serum potassium in the target range (3.8 mEq/L to < 5. 1 mEq/L).

To treat hyperkalemia, patiromer can be used with the following dosing:

• For patients with a baseline serum potassium of 5.1 mEq/L to < 5.5 mEq/L, start with 8.4 grams per day (as a divided dose)
• For patients with a baseline serum potassium of 5.5 mEq/L to < 6.5 mEq/L, start with 16.8 grams per day (as a divided dose)
• Titrate the dose as needed to maintain serum potassium in the target range (3.8 mEq/L to < 5.1 mEq/L) 2.

Alternatively, calcium chloride may be used to combat the deleterious effects of hyperkalemia, pending correction of the increased potassium level in the extracellular fluid, as measured by electrocardiogram (ECG) 3.

From the Research

Treatment Options for Hyperkalemia

• The treatment of hyperkalemia involves several strategies, including the use of glucose and insulin, bicarbonate, calcium gluconate, beta-2 agonists, and dialysis 4, 5, 6.
• Medications such as sodium polystyrene sulfonate (SPS), sodium zirconium cyclosilicate (SZC), and patiromer can also be used to reduce serum potassium levels 4.
• Insulin is a reliable agent for promoting the transcellular shift of potassium, and albuterol can be used alone or to augment the effect of insulin 5, 7.
• Hemodialysis is a rapid and reliable method for removing potassium from the body and lowering serum potassium levels 5, 6, 8.

Emergency Treatment

• In cases of severe hyperkalemia, treatment should be started with calcium gluconate to stabilize cardiomyocyte membranes, followed by insulin injection and beta-agonist administration 6, 7, 8.
• Electrocardiographic changes or a rapid rise in serum potassium indicate that hyperkalemia is potentially life-threatening and require immediate attention 6, 8.

Long-term Management

• The management of hyperkalemia includes the elimination of reversible causes, such as diet and medications, and the use of oral binding resins or hemodialysis to facilitate the removal of potassium from the body 5, 6, 8.
• Urine potassium, creatinine, and osmolarity should be obtained to determine the cause of hyperkalemia and direct long-term treatment 8.