How do I manage hyperkalemia?

Management of Hyperkalemia

For hyperkalemia management, use a stepwise approach based on severity, starting with calcium gluconate for cardiac stabilization in severe cases, followed by insulin with glucose and beta-agonists for intracellular potassium shifting, and then methods to eliminate potassium from the body including potassium binders, diuretics, or dialysis. 1, 2

Classification and Assessment

• Classify hyperkalemia as mild (5.0-5.9 mEq/L), moderate (6.0-6.4 mEq/L), or severe (≥6.5 mEq/L) 2
• Evaluate for ECG changes including peaked T waves, flattened P waves, prolonged PR interval, and widened QRS, which indicate urgent treatment regardless of potassium level 2
• Identify high-risk patients: those with chronic kidney disease, heart failure, diabetes, or taking RAAS inhibitors 2

Acute Management Algorithm

Step 1: Cardiac Membrane Stabilization (for severe hyperkalemia or ECG changes)

• Administer calcium gluconate 10%: 15-30 mL IV over 2-5 minutes 3, 2
• Effects begin within 1-3 minutes but are temporary (30-60 minutes) and do not reduce serum potassium 1, 2
• If no effect is observed within 5-10 minutes, another dose may be given 1

Step 2: Intracellular Potassium Shifting

• Administer insulin with glucose: 10 units regular insulin IV with 25-50g glucose (onset within 15-30 minutes, lasts 4-6 hours) 3, 2
• Consider beta-agonists (e.g., albuterol nebulizer) to enhance intracellular potassium shift 3, 2
• For patients with concurrent metabolic acidosis, administer sodium bicarbonate to promote potassium excretion 1, 2

Step 3: Potassium Elimination

• Hemodialysis is the most effective method for severe hyperkalemia, especially in patients with renal failure 1, 3, 2
• Loop or thiazide diuretics can increase renal potassium excretion in patients with adequate kidney function 1, 2
• Potassium binders can be used, but sodium polystyrene sulfonate (SPS) should not be used for emergency treatment due to its delayed onset of action 4

Chronic Hyperkalemia Management

Medication Review and Adjustment

• Review and adjust medications that contribute to hyperkalemia (ACE inhibitors, ARBs, MRAs, NSAIDs, beta-blockers) 2
• Consider using loop or thiazide diuretics to promote urinary potassium excretion 1, 3

Potassium Binders

• Newer FDA-approved potassium binders (patiromer and sodium zirconium cyclosilicate) are preferred for long-term management 1, 3, 2
• For sodium polystyrene sulfonate (when newer agents unavailable):
  • Oral dose: 15-60g daily, divided as 15g (four level teaspoons) 1-4 times daily 4
  • Rectal dose: 30-50g every six hours 4
  • Administer at least 3 hours before or after other oral medications 4

Special Considerations

Monitoring

• Monitor serum potassium during therapy as severe hypokalemia may occur 4
• Monitor calcium and magnesium levels, as small amounts can be lost during treatment 4
• For patients on RAAS inhibitors, assess potassium levels 7-10 days after starting or increasing doses 2

Cautions

• Avoid sodium polystyrene sulfonate with sorbitol due to risk of intestinal necrosis 5, 4
• Monitor patients sensitive to sodium intake (heart failure, hypertension, edema) when using sodium-containing treatments 4
• A team approach involving specialists, primary care physicians, and other healthcare professionals is optimal for chronic hyperkalemia management 1, 2

Pitfalls to Avoid

• Do not rely solely on sodium polystyrene sulfonate for emergency treatment of life-threatening hyperkalemia due to its delayed onset of action 4
• Do not discontinue RAAS inhibitors prematurely; consider potassium binders to maintain these beneficial medications 1, 6
• Do not forget to monitor glucose levels when administering insulin to prevent hypoglycemia, especially in patients with low baseline glucose, no history of diabetes, female sex, or altered renal function 2