What is the treatment for hyperkalemia?

Treatment for Hyperkalemia

Hyperkalemia requires a three-step approach: immediate cardiac membrane stabilization with intravenous calcium, shifting potassium into cells 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, 2

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

Administer intravenous calcium first in any patient with ECG changes or severe hyperkalemia 2

• Calcium chloride (10%): 5-10 mL (500-1000 mg) IV over 2-5 minutes - preferred due to more rapid increase in ionized calcium 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
• Critical caveat: Calcium does NOT lower serum potassium - it only protects against arrhythmias 2
• Administer through central venous catheter when possible to avoid tissue injury from extravasation 2
• Monitor heart rate during administration and stop if symptomatic bradycardia occurs 2

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

Initiate these therapies immediately after calcium administration:

Insulin with Glucose (First-Line)

• 10 units regular insulin IV with 25g glucose (50 mL of D50W) over 15-30 minutes 1, 2
• Onset within 15-30 minutes, effects last 4-6 hours 1, 2
• Can be repeated every 4-6 hours if hyperkalemia persists 1
• Monitor glucose every 2-4 hours to avoid hypoglycemia 1
• Do not administer if baseline potassium <3.3 mEq/L 1
• Higher hypoglycemia risk in patients with low baseline glucose, no diabetes, female sex, and altered renal function 1

Beta-2 Agonists

• Nebulized albuterol: 10-20 mg over 15 minutes 1, 2
• Can be used alone or in combination with insulin/glucose 2
• Reduces serum potassium by approximately 0.5-1.0 mEq/L 2
• Does not increase potassium excretion - only provides temporary benefit 2

Sodium Bicarbonate (Only if Metabolic Acidosis Present)

• 50 mEq IV over 5 minutes 1, 2
• Indicated ONLY when concurrent metabolic acidosis exists (pH <7.35, bicarbonate <22 mEq/L) 1
• Effects take 30-60 minutes to manifest 1
• Promotes potassium excretion through increased distal sodium delivery 1

Important warning: Temporary measures provide only transient effects (1-4 hours), and rebound hyperkalemia can occur after 2 hours 2

Step 3: Eliminate Potassium From Body (Definitive Treatment)

Loop Diuretics (If Adequate Renal Function)

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

Potassium Binders

For Non-Emergency Chronic Management:

• Patiromer (FDA-approved) - preferred for long-term management 1, 3
• Sodium zirconium cyclosilicate (FDA-approved) - safer alternative to traditional resins 2
• Limitation: These agents should NOT be used as emergency treatment due to delayed onset of action 4, 3

For Subacute Treatment:

• Sodium polystyrene sulfonate (Kayexalate): 15-50 g orally or rectally with sorbitol 2
• Reserved for subacute treatment, not emergency use 4, 5

Hemodialysis

• Most effective method for severe hyperkalemia, especially in renal failure 1, 2
• Indicated for cases refractory to medical treatment 6, 7
• Most reliable method to remove potassium from the body 6

Chronic and Recurrent Hyperkalemia Management

For Patients on RAAS Inhibitors (ACE Inhibitors, ARBs, Mineralocorticoid Antagonists)

When potassium >5.0 mEq/L:

• Initiate approved potassium-lowering agent 1, 2
• Maintain RAAS inhibitor therapy unless alternative treatable cause identified 1, 2
• Using potassium binders to maintain life-saving RAAS inhibitors is preferable to discontinuing therapy 2
• Monitor potassium levels 7-10 days after starting or increasing RAAS inhibitor doses 1

When potassium >6.5 mEq/L:

• Discontinue or reduce RAAS inhibitor temporarily 1, 2
• Initiate potassium-lowering agent 1, 2
• Monitor potassium levels closely 1, 2

Medication Review

• Review and adjust medications contributing to hyperkalemia: ACE inhibitors, ARBs, mineralocorticoid antagonists, NSAIDs, beta-blockers 1, 2
• Loop or thiazide diuretics can promote urinary potassium excretion 1

High-Risk Populations Requiring Frequent Monitoring

• Chronic kidney disease 1
• Heart failure 1
• Diabetes mellitus 1
• Cardiovascular disease on RAAS inhibitors 1

Critical Clinical Pitfalls

• Absent or atypical ECG changes do not exclude the necessity for immediate intervention 7
• Monitor potassium levels closely during treatment to avoid overcorrection and hypokalemia 2
• Initiate potassium-lowering agents early to prevent rebound hyperkalemia 2
• Team approach involving specialists, primary care physicians, and other healthcare professionals is optimal for chronic management 1