What are the doses of insulin, glucose, and albuterol for treating moderate hyperkalemia?

Treatment Doses for Moderate Hyperkalemia

For moderate hyperkalemia (potassium 6.0-6.4 mEq/L), administer 10 units of regular insulin IV with 25 grams of glucose (50 mL of D50W) over 15-30 minutes, combined with 10-20 mg of nebulized albuterol over 15 minutes. 1

Insulin and Glucose Dosing

Standard adult protocol:

• Insulin: 10 units of regular insulin IV 1, 2
• Glucose: 25 grams administered as 50 mL of D50W 1, 2
• Administration time: Over 15-30 minutes 1, 2
• Insulin-to-glucose ratio: 1 unit of insulin per 2.5 grams of glucose 2

The 10-unit insulin dose is superior to lower doses—a study comparing 5 versus 10 units in patients with moderate renal dysfunction showed 10 units lowered potassium significantly more (-0.9 mmol/L vs -0.63 mmol/L, p=0.001) without increasing hypoglycemia risk 3. The effect begins within 15-30 minutes and lasts 4-6 hours 1.

Alternative glucose formulations:

• D25W can be used as an acceptable alternative, requiring 100 mL to deliver 25 grams of glucose 1
• D10W infusion is an effective alternative during D50W shortages, showing similar hypoglycemia prevention rates 4

Pediatric dosing differs substantially:

• Insulin: 0.1 unit/kg IV 2
• Glucose: 400 mg/kg (use D10W exclusively) 2
• The pediatric insulin-to-glucose ratio is 1 unit per 4 grams of glucose, reflecting higher hypoglycemia risk in children 2

Albuterol Dosing

Nebulized albuterol: 10-20 mg administered over 15 minutes 1

This beta-2 agonist stimulates the Na+/K+-ATPase pump, shifting potassium into cells with onset in 15-30 minutes and duration of 4-6 hours 1. The combination of insulin/glucose with albuterol provides additive potassium-lowering effects 5.

Critical Clinical Considerations

Monitor for hypoglycemia aggressively:

• Recheck blood glucose at 30,60, and 120 minutes after insulin administration 2
• Approximately 20% of patients experience hypoglycemia with standard dosing 6
• Never administer insulin without glucose—this dramatically increases hypoglycemia risk 2

Anticipate rebound hyperkalemia:

• Both insulin/glucose and albuterol provide only temporary effects lasting 4-6 hours 1
• Rebound hyperkalemia can occur after 2 hours 1
• Recheck potassium levels as the insulin effect wanes 2
• Definitive potassium removal strategies (diuretics, potassium binders, or dialysis) must be initiated concurrently 1, 2

Higher-risk patients requiring modified dosing:

• Patients with low baseline glucose, no diabetes history, female gender, abnormal renal function, or lower body weight should receive 50 grams of glucose instead of 25 grams with the standard 10-unit insulin dose 2
• For severe hyperkalemia (≥6.5 mEq/L) or marked ECG changes, consider 20 units of insulin with 60 grams of glucose over 60 minutes, though this increases hypoglycemia risk without substantial improvement in potassium reduction 2, 6

Complete treatment algorithm for moderate hyperkalemia:

1. Cardiac membrane stabilization (if ECG changes present): Calcium chloride 10%: 5-10 mL IV over 2-5 minutes 1
2. Shift potassium into cells (primary treatment): Insulin 10 units + glucose 25g over 15-30 minutes PLUS albuterol 10-20 mg nebulized 1
3. Eliminate potassium from body (concurrent with step 2): Loop diuretics, potassium binders, or hemodialysis depending on renal function 1