What is the treatment for metabolic alkalosis?

From the Guidelines

Treatment for alkalosis should focus on addressing the underlying cause and restoring normal pH balance, with the most recent and highest quality study suggesting that correcting fluid and electrolyte imbalances is crucial. According to the study published in 2021 1, salt supplementation with sodium chloride can support extracellular volume and improve electrolyte abnormalities, with a recommended dose of at least 5–10 mmol/kg/d. Additionally, potassium supplementation with potassium chloride can help address hypokalemia, but potassium salts like citrate should be avoided as they can worsen the metabolic disturbance by aggravating the alkalosis.

For metabolic alkalosis, treatment includes:

• Correcting fluid and electrolyte imbalances with normal saline infusion
• Potassium chloride supplementation if hypokalemic
• Acetazolamide (250-500 mg orally or IV every 6-12 hours) to increase renal bicarbonate excretion
• In severe cases, dilute hydrochloric acid may be administered in an ICU setting

For respiratory alkalosis, the primary approach is:

• Treating the underlying cause (anxiety, pain, sepsis)
• Encouraging slower, deeper breathing patterns
• Rebreathing into a paper bag can temporarily help in acute hyperventilation by increasing CO2 levels
• Benzodiazepines like diazepam (2-10 mg) may be used for anxiety-induced hyperventilation
• Mechanical ventilation adjustments are necessary for ventilated patients

It is essential to address electrolyte abnormalities, particularly chloride, potassium, and calcium deficiencies, in all cases of alkalosis. Treatment should be monitored with serial arterial blood gases and electrolyte measurements to prevent overcorrection, which can lead to metabolic acidosis or other complications. The study published in 2008 1 provides dosage guidelines for various medications, but the most recent study 1 takes precedence in guiding treatment for alkalosis.

From the Research

Treatment of Metabolic Alkalosis

• The treatment of metabolic alkalosis is usually supportive and based on the cause of the alkalosis 2
• Conventional conservative treatment involves meeting the patient's fluid and electrolyte needs and allowing the body to correct the alkalosis through its own mechanisms 3
• In severe cases, administration of carbonic anhydrase inhibitors, acid infusion, and low bicarbonate dialysis may be necessary 4
• Mineral acid administration, such as intravenous ammonium chloride or dilute hydrochloric acid, may be instituted when metabolic alkalosis needs to be resolved quickly or when conventional therapy cannot be tolerated 3
• The primary drug of choice for patients with severe metabolic alkalosis is intravenous ammonium chloride, while patients with hepatic or severe renal dysfunction should receive dilute hydrochloric acid via a central-venous catheter 3

Factors Affecting Treatment

• Factors that interfere with the kidney's ability to eliminate excess bicarbonate, such as volume contraction, low glomerular filtration rate, potassium deficiency, hypochloremia, aldosterone excess, and elevated arterial carbon dioxide, can impair the correction of metabolic alkalosis 5
• Understanding the generation and maintenance mechanisms of metabolic alkalosis helps direct appropriate intervention and correction of this disorder 6

Clinical States Associated with Metabolic Alkalosis

• Metabolic alkalosis is associated with various clinical states, including vomiting, mineralocorticoid excess, licorice ingestion, diuretic administration, and genetic diseases such as Bartter syndrome, Gitelman syndrome, and cystic fibrosis 4, 5