What is the treatment for metabolic alkalosis?

From the Guidelines

To correct metabolic alkalosis, first identify and address the underlying cause, and consider administering normal saline (0.9% NaCl) intravenously to restore intravascular volume and promote renal bicarbonate excretion, as recommended by the most recent guidelines 1. The treatment approach should prioritize the correction of volume depletion and the promotion of renal bicarbonate excretion. The following steps can be taken:

• Administer normal saline (0.9% NaCl) intravenously to restore intravascular volume and promote renal bicarbonate excretion, typically at rates of 100-200 mL/hour depending on the severity and the patient's cardiac status.
• For chloride-responsive alkalosis (with low urine chloride <20 mEq/L), volume repletion alone may be sufficient.
• In cases of severe alkalosis (pH >7.60), consider administering acetazolamide 250-500 mg orally or intravenously every 6 hours to enhance bicarbonate excretion, as suggested by the KDIGO 2021 clinical practice guideline for the management of glomerular diseases 1.
• For chloride-resistant alkalosis (with high urine chloride >20 mEq/L), often seen in conditions like primary hyperaldosteronism, specific treatments targeting the underlying disorder are necessary.
• Potassium replacement (oral or IV KCl) is frequently required as hypokalemia commonly accompanies metabolic alkalosis and its correction helps resolve the alkalosis.
• In extreme cases where rapid correction is needed, dilute hydrochloric acid (0.1-0.2 N HCl) may be administered through a central venous catheter, but this requires intensive monitoring and is rarely necessary. It is essential to monitor for adverse effects of diuretics, such as hypokalemia, hyponatremia, and impaired GFR, as highlighted in the KDIGO 2021 guideline 1. The use of loop diuretics, such as furosemide, should be cautious, as high doses can cause severe electrolyte disturbances and metabolic alkalosis, as noted in the guidelines on the management of ascites in cirrhosis 1. Overall, the treatment of metabolic alkalosis should focus on addressing the underlying cause, restoring volume and electrolyte balance, and promoting renal bicarbonate excretion, with consideration of the most recent and highest quality evidence 1.

From the Research

Treatment of Metabolic Alkalosis

The treatment of metabolic alkalosis involves correcting the underlying cause of the condition and addressing any associated electrolyte imbalances. The following are some of the key treatment strategies:

• Correction of fluid and electrolyte status: This is the cornerstone of treatment for metabolic alkalosis, as it helps to restore normal acid-base balance 2, 3.
• Administration of acid: In some cases, acid may be administered to help correct the alkalosis. This can include intravenous hydrochloric acid, ammonium chloride, or arginine monohydrochloride 2.
• Use of carbonic anhydrase inhibitors: Acetazolamide is a carbonic anhydrase inhibitor that can be used to treat metabolic alkalosis. It works by increasing the excretion of bicarbonate in the urine 4, 5.
• Dialysis: In severe cases of metabolic alkalosis, dialysis may be necessary to remove excess bicarbonate from the blood 2, 6.
• Addressing underlying causes: It is also important to address the underlying cause of the metabolic alkalosis, such as vomiting, mineralocorticoid excess, or diuretic use 3, 6.

Specific Treatment Strategies

The following are some specific treatment strategies for metabolic alkalosis:

• For vomiting-induced chloride depletion alkalosis, infusion of potassium chloride can help restore normal acid-base balance 3.
• For patients with hepatic dysfunction, dilute hydrochloric acid may be given intravenously through a central-venous catheter 2.
• For patients with severe renal dysfunction, alternative therapies such as dialysis may be necessary 2, 6.

Key Considerations

The following are some key considerations when treating metabolic alkalosis:

• The treatment of metabolic alkalosis should be individualized based on the underlying cause and severity of the condition 2, 6.
• It is important to monitor the patient's acid-base status and electrolyte levels closely during treatment 4, 5.
• The use of acid or carbonic anhydrase inhibitors should be done with caution, as they can have potential side effects 2, 5.