What is the guideline to treat hyperkalemia?

Hyperkalemia Management

Acute Hyperkalemia Treatment

For acute hyperkalemia, particularly with ECG changes or potassium ≥6.5 mEq/L, immediately administer IV calcium gluconate (15-30 mL of 10% solution over 2-5 minutes) to stabilize cardiac membranes, followed by insulin with glucose and nebulized albuterol to shift potassium intracellularly. 1

Severity Classification

• Mild hyperkalemia: 5.0-5.9 mEq/L 1
• Moderate hyperkalemia: 6.0-6.4 mEq/L 1
• Severe hyperkalemia: ≥6.5 mEq/L 1
• ECG changes (peaked T waves, flattened P waves, prolonged PR interval, widened QRS) indicate urgent treatment regardless of potassium level 1

Immediate Stabilization (Within 1-3 Minutes)

Calcium administration is the first-line treatment for cardiac membrane stabilization:

• Calcium gluconate 10%: 15-30 mL IV over 2-5 minutes 1
• Calcium chloride 10%: 5-10 mL IV over 2-5 minutes 1
• Effects begin within 1-3 minutes but last only 30-60 minutes 1
• Repeat dosing may be necessary if no ECG improvement within 5-10 minutes 1
• Calcium does not reduce serum potassium—it only protects the heart temporarily 1

Intracellular Potassium Shift (Within 15-30 Minutes)

After calcium, immediately administer agents to shift potassium into cells:

• Insulin with glucose: 10 units regular insulin IV with 25-50 grams glucose (unless blood glucose >250 mg/dL) 1

  • Onset: 15-30 minutes 1
  • Duration: 4-6 hours 1
  • Monitor glucose closely to prevent hypoglycemia 1
  • Can be repeated every 4-6 hours if hyperkalemia persists 1

• Nebulized albuterol: 20 mg in 4 mL nebulized over 10 minutes 1

  • Onset: 15-30 minutes 1
  • Duration: 2-4 hours 1
  • Use as adjunctive therapy with insulin/glucose 1

• Sodium bicarbonate: ONLY if concurrent metabolic acidosis (pH <7.35, bicarbonate <22 mEq/L) 1

  • Onset: 30-60 minutes 1
  • Do not use in patients without metabolic acidosis—it is ineffective and potentially harmful 1

Potassium Removal from the Body

Temporizing measures only buy time—definitive treatment requires removing potassium:

• Loop diuretics (furosemide 40-80 mg IV) if adequate kidney function (eGFR >30 mL/min) 1

• Sodium zirconium cyclosilicate (SZC/Lokelma): 10 g three times daily for 48 hours, then 5-15 g once daily 1, 2

  • Onset: 1 hour 1
  • FDA-approved for acute and chronic hyperkalemia 2
  • Each 5 g dose contains approximately 400 mg sodium—monitor for edema 2

• Patiromer (Veltassa): 8.4 g once daily, titrated up to 25.2 g daily 1

  • Onset: ~7 hours 1
  • Better for chronic management than acute treatment 1

• Hemodialysis is the most effective method for severe hyperkalemia, especially in renal failure, oliguria, or cases unresponsive to medical management 1, 3

Chronic Hyperkalemia Management

For chronic hyperkalemia in patients on RAAS inhibitors (ACE inhibitors, ARBs, mineralocorticoid antagonists), initiate newer potassium binders (patiromer or SZC) while maintaining RAAS inhibitor therapy—do not discontinue these life-saving medications. 1

Treatment Algorithm Based on Potassium Level

Potassium 5.0-6.5 mEq/L on RAAS inhibitors:

• Initiate patiromer or SZC 1
• Maintain RAAS inhibitor therapy unless alternative treatable cause identified 1
• Eliminate contributing medications: NSAIDs, trimethoprim, heparin, beta-blockers, potassium supplements, salt substitutes 1

Potassium >6.5 mEq/L:

• Discontinue or reduce RAAS inhibitor temporarily 1
• Initiate potassium-lowering agent immediately 1
• Restart RAAS inhibitor at lower dose once potassium <5.0 mEq/L with concurrent potassium binder 1

Medication Review

Critical medications to eliminate or reduce:

• NSAIDs and COX-2 inhibitors 1
• Potassium supplements and salt substitutes 1
• Trimethoprim 1
• Heparin 1
• Beta-blockers (if not essential) 1
• Potassium-sparing diuretics (spironolactone, amiloride, triamterene) 1

Diuretic Therapy

Loop or thiazide diuretics promote urinary potassium excretion:

• Furosemide 40-80 mg daily if eGFR >30 mL/min 1
• Titrate to maintain euvolemia, not primarily for potassium management 1

Monitoring Protocol

Frequency of potassium monitoring depends on clinical context:

• After starting or escalating RAAS inhibitors: check within 7-10 days 1
• After initiating potassium binder: check at 1 week, then 1-2 weeks, 3 months, then every 6 months 1
• High-risk patients (CKD, heart failure, diabetes): more frequent monitoring individualized to risk 1
• After acute treatment with insulin/glucose: recheck within 1-2 hours 1
• After IV calcium: recheck within 5-10 minutes if no ECG improvement 1

Special Populations

Patients with CKD Stage 4-5:

• Optimal potassium range is broader: 3.3-5.5 mEq/L for stage 4-5 CKD 1
• Maintain RAAS inhibitors aggressively using potassium binders—these drugs slow CKD progression 1
• Dialysis is reserved for severe cases unresponsive to medical management 1

Patients with heart failure:

• Target potassium 4.0-5.0 mEq/L—both hypokalemia and hyperkalemia increase mortality 1
• Do not discontinue RAAS inhibitors or mineralocorticoid antagonists—use potassium binders instead 1

Critical Pitfalls to Avoid

• Do not rely solely on ECG findings—they are highly variable and less sensitive than laboratory tests 1
• Do not use sodium bicarbonate in patients without metabolic acidosis—it is only indicated when pH <7.35 1
• Always administer glucose with insulin to prevent hypoglycemia 1
• Remember that calcium, insulin, and beta-agonists do not remove potassium—they only temporize 1
• Verify the result is not pseudohyperkalemia from hemolysis, repeated fist clenching, or poor phlebotomy technique before initiating treatment 1
• Avoid sodium polystyrene sulfonate (Kayexalate) for acute management—it has delayed onset and risk of bowel necrosis 1
• When initiating potassium-lowering therapy, monitor closely for hypokalemia, which may be even more dangerous than hyperkalemia 1