What is the treatment for hyperkalemia?

Treatment of Hyperkalemia

The treatment of hyperkalemia requires a stepwise approach based on severity, with immediate cardiac membrane stabilization using intravenous calcium for severe hyperkalemia (≥6.5 mEq/L) or in the presence of ECG changes, followed by insulin with glucose to shift potassium into cells, and elimination strategies including diuretics, potassium binders, or hemodialysis. 1, 2

Classification of Hyperkalemia

• Mild: 5.0-5.9 mEq/L 1, 2
• Moderate: 6.0-6.4 mEq/L 1, 2
• Severe: ≥6.5 mEq/L 1, 2

Acute Management Algorithm

Step 1: Cardiac Membrane Stabilization (Immediate Effect)

• Administer intravenous calcium for cardiac protection if severe hyperkalemia (≥6.5 mEq/L) or ECG changes are present 2
  • Calcium gluconate (10%): 15-30 mL IV over 2-5 minutes, OR 1, 2
  • Calcium chloride (10%): 5-10 mL IV over 2-5 minutes (preferred for more rapid effect but requires central venous access) 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)

• Insulin with glucose: 10 units regular insulin IV with 25g glucose (50 mL of D50W) over 15-30 minutes 1, 2
• Nebulized beta-2 agonists: Albuterol 10-20 mg nebulized over 15 minutes 2
• Sodium bicarbonate: 50 mEq IV over 5 minutes (most effective in patients with concurrent metabolic acidosis) 1, 2
• Effects of these interventions begin within 15-30 minutes and last 4-6 hours 1, 2

Step 3: Eliminate Potassium from Body

• Loop diuretics: Furosemide 40-80 mg IV (effective only in patients with adequate renal function) 1, 2
• Cation exchange resins or newer potassium binders:
  • Sodium polystyrene sulfonate (Kayexalate): 15-50 g orally or rectally 2
  • Newer agents: Patiromer or sodium zirconium cyclosilicate (preferred over SPS due to better safety profile) 1, 2
• Hemodialysis: Most effective method for severe or refractory hyperkalemia, especially in patients with renal failure 1, 2

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 excretion of potassium 1
• Consider newer FDA-approved potassium binders (patiromer, sodium zirconium cyclosilicate) for long-term management 1, 3
• Monitor potassium levels regularly, especially in high-risk patients (CKD, heart failure, diabetes) 1

Important Clinical Considerations

• Sodium polystyrene sulfonate should not be used as an emergency treatment for life-threatening hyperkalemia due to its delayed onset of action 4
• Temporary measures (insulin/glucose, albuterol) provide only transient effects, and rebound hyperkalemia can occur after 2 hours 2
• ECG changes requiring urgent treatment include peaked T waves, flattened P waves, prolonged PR interval, and widened QRS 1, 2
• Calcium administration is primarily for cardiac membrane stabilization and does not lower serum potassium levels 1, 2, 5
• Hemodialysis remains the most reliable method to remove potassium from the body in cases refractory to medical treatment 6, 7

Special Populations

• For patients on RAAS inhibitors with hyperkalemia >5.0 mEq/L, consider initiating a potassium-lowering agent while maintaining RAAS inhibitor therapy unless severe hyperkalemia is present 2
• In patients with malignant hyperthermia and hyperkalemia, calcium should only be used in extreme cases as it may contribute to calcium overload of the myoplasm 1