Could any of these medications be causing hyperkalemia?

Medication-Induced Hyperkalemia Assessment

None of the medications on this list are likely causing the hyperkalemia, though calcium acetate theoretically could contribute in rare circumstances. The patient is already appropriately receiving sodium polystyrene sulfonate for hyperkalemia treatment, and the focus should be on identifying non-medication causes such as chronic kidney disease, dietary potassium intake, or endocrine disorders rather than discontinuing any of these medications 1.

Medications That DO NOT Cause Hyperkalemia

The medication list contains no renin-angiotensin-aldosterone system (RAAS) inhibitors, which are the most common drug-related cause of hyperkalemia 1, 2. Specifically absent are:

• No ACE inhibitors (e.g., lisinopril, enalapril) 3
• No ARBs (e.g., losartan, valsartan) 3
• No mineralocorticoid receptor antagonists (spironolactone, eplerenone) 3
• No potassium-sparing diuretics (amiloride, triamterene) 3
• No direct renin inhibitors (aliskiren) 3, 1

Low-Risk Medications on This List

The following medications have minimal to no association with hyperkalemia:

• Insulin (glargine and aspart): Actually lowers potassium by driving it intracellularly 4
• Atorvastatin: No hyperkalemia risk 3
• Apixaban: No effect on potassium homeostasis 1
• Pantoprazole: No hyperkalemia association 3
• Tramadol, pregabalin, trazodone: No potassium effects 1
• Bisacodyl, senna, polyethylene glycol, Fleet enema: Laxatives do not cause hyperkalemia 1
• Midodrine: No potassium effects 3
• Vancomycin: Not associated with hyperkalemia 1

Theoretical Concern: Calcium Acetate

Calcium acetate is the only medication requiring consideration, though it is an unlikely culprit 1:

• Calcium acetate is a phosphate binder used for hyperphosphatemia in chronic kidney disease patients 3
• While calcium itself does not cause hyperkalemia, the underlying renal dysfunction that necessitates phosphate binders is the actual problem 2, 4
• The presence of calcium acetate on this list suggests significant chronic kidney disease, which is the most likely cause of hyperkalemia rather than the medication itself 2, 5

Clinical Approach to This Patient's Hyperkalemia

Evaluate these non-medication factors systematically 4:

1. Renal function: Check current creatinine clearance—hyperkalemia with mild-to-moderate renal failure suggests additional causes beyond kidney disease alone 5

2. Dietary potassium intake: Review consumption of high-potassium foods, salt substitutes, or potassium supplements 1, 4

3. Endocrine evaluation: Consider hyporeninemic hypoaldosteronism, especially if diabetic nephropathy is present 4

4. Hidden potassium sources: Stored blood products, herbal supplements (alfalfa, dandelion, hawthorne berry), or amino acid supplements 1

Key Pitfall to Avoid

Do not attribute hyperkalemia to renal insufficiency alone if kidney function is only mildly-to-moderately impaired 5. Severe renal insufficiency (GFR <30 mL/min) is generally required for hyperkalemia from kidney disease alone 3, 5. The combination of calcium acetate use and hyperkalemia strongly suggests advanced CKD as the primary etiology rather than medication effect 2, 4.