What is the order of medications to give for hyperkalemia (elevated potassium levels)?

Order of Medications for Hyperkalemia Treatment

For hyperkalemia with ECG changes or potassium ≥6.5 mEq/L, immediately administer intravenous calcium (calcium chloride 10%: 5-10 mL or calcium gluconate 10%: 15-30 mL over 2-5 minutes) to stabilize cardiac membranes, followed simultaneously by insulin with glucose (10 units regular insulin IV with 25g glucose over 15-30 minutes) and nebulized albuterol (10-20 mg over 15 minutes) to shift potassium into cells, then initiate potassium elimination with loop diuretics or hemodialysis depending on renal function. 1, 2, 3

Step-by-Step Treatment Algorithm

Step 1: Cardiac Membrane Stabilization (IMMEDIATE - within 1-3 minutes)

This is your first intervention for any hyperkalemia with ECG changes (peaked T waves, flattened P waves, prolonged PR interval, widened QRS) or potassium ≥6.5 mEq/L. 1, 2

• Calcium chloride (10%): 5-10 mL (500-1000 mg) IV over 2-5 minutes 1, 2

  • Preferred in critically ill patients as it provides more rapid increase in ionized calcium 1
  • Administer through central line when possible due to tissue necrosis risk with extravasation 1
  • Monitor heart rate during administration; stop if symptomatic bradycardia occurs 1

• Alternative: Calcium gluconate (10%): 15-30 mL IV over 2-5 minutes 1, 2

  • Safer for peripheral IV access 1
  • Less tissue damage if extravasation occurs 1

• Onset: 1-3 minutes; Duration: 30-60 minutes 1, 2

• Critical caveat: Calcium does NOT lower potassium—it only protects the heart temporarily 1, 2

• Repeat dose: If no ECG improvement within 5-10 minutes, give another dose 2

Step 2: Shift Potassium into Cells (START SIMULTANEOUSLY - onset 15-30 minutes)

Begin these therapies immediately after or concurrent with calcium administration. Do not wait for calcium to finish. 1, 2

Primary Shifting Agents (use BOTH together):

• Insulin + Glucose: 10 units regular insulin IV with 25g glucose (50 mL D50W) over 15-30 minutes 1, 2, 3

  • Onset: 15-30 minutes; Duration: 4-6 hours 1, 2
  • Monitor glucose closely to prevent hypoglycemia 1
  • Can repeat every 4-6 hours if hyperkalemia persists 1
  • Recheck potassium within 1-2 hours after administration 2

• Nebulized albuterol: 10-20 mg over 15 minutes 1, 2, 3

  • Onset: 15-30 minutes; Duration: 2-4 hours 1, 2
  • Augments insulin effect when used together 1, 4
  • Can lower potassium by 0.5-1.0 mEq/L 1

Adjunctive Shifting Agent (use ONLY if metabolic acidosis present):

• Sodium bicarbonate: 50 mEq IV over 5 minutes 1, 2
  • ONLY use if concurrent metabolic acidosis (pH <7.35, bicarbonate <22 mEq/L) 1, 2
  • Onset: 30-60 minutes 2
  • Do NOT use routinely without acidosis—it is ineffective 2, 5

Critical warning: All shifting agents are temporary (lasting 1-6 hours) and rebound hyperkalemia can occur after 2 hours. 1 You MUST proceed to Step 3 for definitive potassium removal. 1

Step 3: Eliminate Potassium from Body (START WITHIN 1-2 HOURS - definitive treatment)

Choose based on renal function and severity. 1, 2

If adequate renal function (eGFR >30 mL/min):

• Loop diuretics: Furosemide 40-80 mg IV 1, 2
  • Increases renal potassium excretion 1, 2
  • Only effective with adequate kidney function 1, 2
  • Titrate to maintain euvolemia 2

For subacute management or inadequate renal response:

• Newer potassium binders (PREFERRED): 1, 2

  • Sodium zirconium cyclosilicate (SZC/Lokelma): 10g three times daily for 48 hours, then 5-15g once daily 2
    • Onset: ~1 hour 2
    • Safer than older resins 1
  • Patiromer (Veltassa): 8.4g once daily, titrate up to 25.2g daily 2
    • Onset: ~7 hours 2

• Older resin (use only if newer agents unavailable):

  • Sodium polystyrene sulfonate (Kayexalate): 15-50g orally or rectally with sorbitol 1
    • Delayed onset, risk of bowel necrosis 2
    • NOT effective for acute management 5

If severe hyperkalemia (≥6.5 mEq/L) with renal failure or refractory to medical treatment:

• Hemodialysis 1, 2, 3
  • Most effective and reliable method for potassium removal 1, 2, 5
  • Definitive treatment for end-stage renal disease patients 1, 5
  • Use for oliguria, acute kidney injury, or failure of medical management 2

Severity-Based Treatment Protocols

Mild Hyperkalemia (5.0-5.9 mEq/L, no ECG changes):

• Review and stop contributing medications (ACE inhibitors, ARBs, NSAIDs, potassium supplements) 1, 2
• Initiate potassium binder if on RAAS inhibitors 1, 2
• Monitor potassium within 7-10 days 2

Moderate Hyperkalemia (6.0-6.4 mEq/L, no ECG changes):

• Insulin + glucose 2
• Nebulized albuterol 2
• Potassium binder 2
• Consider calcium if any ECG changes develop 2

Severe Hyperkalemia (≥6.5 mEq/L OR any ECG changes):

• ALL THREE STEPS simultaneously: 1, 2, 3
  1. Calcium (immediate)
  2. Insulin + glucose + albuterol (within minutes)
  3. Diuretics or dialysis (within 1-2 hours)

Critical Monitoring Parameters

• Recheck potassium: 2

  • Within 1-2 hours after insulin/glucose or albuterol 2
  • Every 2-4 hours during acute treatment phase 1
  • Within 5-10 minutes if no ECG improvement after calcium 2

• Continuous cardiac monitoring required for severe hyperkalemia 1, 2, 3

Common Pitfalls to Avoid

• Never rely on calcium alone—it does NOT lower potassium, only protects the heart temporarily 1, 2
• Never use bicarbonate without metabolic acidosis—it is ineffective and delays appropriate treatment 2, 5
• Never forget glucose with insulin—hypoglycemia can be life-threatening 1
• Never assume shifting agents are definitive—rebound hyperkalemia occurs within 2-6 hours without potassium elimination 1
• Never use sodium polystyrene sulfonate for acute management—it has delayed onset and serious GI risks 2, 5
• Always check magnesium—hypomagnesemia can worsen cardiac effects 2