What is the treatment for hyperkalemia?

Treatment of Hyperkalemia

Hyperkalemia treatment follows a three-step algorithmic approach: immediate cardiac membrane stabilization with intravenous calcium, shifting potassium intracellularly with insulin/glucose and beta-agonists, and eliminating potassium from the body through diuretics, potassium binders, or hemodialysis. 1, 2

Severity Classification and Initial Assessment

• Mild hyperkalemia: 5.0-5.9 mEq/L 1
• Moderate hyperkalemia: 6.0-6.4 mEq/L 1
• Severe hyperkalemia: ≥6.5 mEq/L (life-threatening) 2
• ECG changes (peaked T waves, flattened P waves, prolonged PR interval, widened QRS) mandate urgent treatment regardless of potassium level 1, 2
• Exclude pseudo-hyperkalemia from hemolysis or improper blood sampling by repeating measurement with appropriate technique before initiating aggressive treatment 1

Step 1: Cardiac Membrane Stabilization (Immediate - Within 1-3 Minutes)

This step does not lower potassium but protects against fatal arrhythmias. 2

• Calcium chloride (10%): 5-10 mL (500-1000 mg) IV over 2-5 minutes is preferred as it provides more rapid increase in ionized calcium than calcium gluconate 2
• Alternative: Calcium gluconate (10%): 15-30 mL IV over 2-5 minutes 1, 2
• Effects begin within 1-3 minutes but last only 30-60 minutes 1, 2
• Administer through central venous catheter when possible to avoid severe skin and soft tissue injury from extravasation 2
• Monitor heart rate during administration and stop if symptomatic bradycardia occurs 2
• Critical caveat: In malignant hyperthermia with hyperkalemia, use calcium only in extremis as it may contribute to myoplasmic calcium overload 1

Step 2: Shift Potassium Intracellularly (Onset 15-30 Minutes, Duration 4-6 Hours)

These are temporary measures; rebound hyperkalemia can occur after 2 hours. 2

Insulin with Glucose (First-Line)

• 10 units regular insulin IV with 25g glucose (50 mL of D50W) over 15-30 minutes 1, 2
• Onset: 15-30 minutes; duration: 4-6 hours 1
• Can be repeated every 4-6 hours as needed with careful monitoring of potassium and glucose 1
• Do not administer if potassium <3.3 mEq/L 1
• Patients at higher risk for hypoglycemia: low baseline glucose, no diabetes history, female sex, altered renal function 1
• Monitor potassium every 2-4 hours after initial administration 1

Beta-2 Agonists

• Nebulized albuterol: 10-20 mg over 15 minutes 1, 2
• Can reduce serum potassium by approximately 0.5-1.0 mEq/L 2
• Does not increase potassium excretion; provides temporary benefit with potential rebound 2

Sodium Bicarbonate (Only with Metabolic Acidosis)

• 50 mEq IV over 5 minutes 2
• Use ONLY if metabolic acidosis is present (pH <7.35, bicarbonate <22 mEq/L) 1
• Effects take 30-60 minutes to manifest 1
• Promotes potassium excretion through increased distal sodium delivery and counters acidosis-induced potassium release 1

Step 3: Eliminate Potassium from Body (Definitive Treatment)

Loop Diuretics

• Furosemide 40-80 mg IV 1, 2
• Effective only in patients with adequate renal function 1, 2
• Can be used with bicarbonate to enhance potassium excretion 1

Potassium Binders

Newer agents (patiromer and sodium zirconium cyclosilicate) are safer alternatives to traditional cation exchange resins. 2

• Sodium polystyrene sulfonate (Kayexalate): 15-50 g orally or rectally with sorbitol 2
• FDA limitation: Should NOT be used as emergency treatment for life-threatening hyperkalemia due to delayed onset of action 3
• Newer potassium binders (patiromer, sodium zirconium cyclosilicate) preferred for chronic management 1, 2

Hemodialysis

• Most effective method for severe hyperkalemia, especially in renal failure or refractory cases 1, 2
• Use when medical treatment fails 2

Chronic Hyperkalemia Management

Medication Review

• Review and adjust medications contributing to hyperkalemia: ACE inhibitors, ARBs, mineralocorticoid antagonists, NSAIDs, beta-blockers 1, 2

RAAS Inhibitor Management Algorithm

For patients on RAAS inhibitors with cardiovascular disease, maintaining these life-saving medications with potassium binders is preferable to discontinuation. 2

• Potassium >5.0 mEq/L: Initiate approved potassium-lowering agent, maintain RAAS inhibitor therapy unless alternative treatable cause identified 1, 2
• Potassium >6.5 mEq/L: Discontinue or reduce RAAS inhibitor temporarily, initiate potassium-lowering agent, monitor closely 1, 2
• Assess potassium levels 7-10 days after starting or increasing RAAS inhibitor doses 1

Long-Term Strategies

• Loop or thiazide diuretics to promote urinary potassium excretion 1
• Newer FDA-approved potassium binders (patiromer, sodium zirconium cyclosilicate) for long-term management 1
• Team approach involving specialists, primary care physicians, and other healthcare professionals 1

Critical Pitfalls to Avoid

• Do not rely solely on ECG findings - they can be highly variable and less sensitive than laboratory tests; absent or atypical ECG changes do not exclude need for immediate intervention 1
• Beware of rebound hyperkalemia after temporary measures (insulin/glucose, albuterol) wear off after 2-4 hours 2
• Initiate potassium-lowering agents early to prevent rebound 2
• Monitor potassium levels closely during treatment to avoid overcorrection and hypokalemia 2
• Do not use sodium bicarbonate without metabolic acidosis - it has poor efficacy as a potassium-lowering agent when used alone 1
• Higher-risk populations (chronic kidney disease, heart failure, diabetes) require more frequent monitoring 1