What is the standard dosing of insulin and Dextrose 50% (D50) for the treatment of hyperkalemia?

From the Guidelines

The standard dosing of insulin and Dextrose 50% (D50) for the treatment of hyperkalemia is 10 U regular insulin and 25 g (50 mL of D50) glucose given IV over 15 to 30 minutes 1.

Key Considerations

• The dose of insulin and D50 can be adjusted based on the patient's response and serum glucose levels.
• It is essential to monitor serum glucose and potassium levels closely during treatment.
• Other treatment options, such as calcium carbonate, hyperosmolar sodium, and beta adrenoceptor agonists, may also be used in conjunction with insulin and D50 to manage hyperkalemia.

Evidence-Based Rationale

• The American Heart Association guidelines recommend the use of glucose plus insulin to manage hyperkalemia, with a specific dose of 25 g (50 mL of D50) glucose and 10 U regular insulin given IV over 15 to 30 minutes 1.
• Another study suggests a dose of 50 IU insulin and 50 mL of 50% Dextrose for adults 1, however, the American Heart Association guidelines are more specific and widely accepted.
• High-dose insulin therapy may also be used in refractory shock, but this is a different context and requires careful monitoring of serum glucose and potassium levels 1.

Clinical Implications

• Insulin and D50 should be administered promptly in patients with hyperkalemia to help shift potassium into cells and reduce the risk of cardiac arrhythmias.
• Close monitoring of serum glucose and potassium levels is crucial to avoid overly aggressive potassium repletion and to adjust the dose of insulin and D50 as needed.

From the Research

Standard Dosing of Insulin and Dextrose 50% (D50) for Hyperkalemia

• The standard dosing of insulin for hyperkalemia is not well established, but studies suggest that a dose of 0.1 units/kg or 5-10 units can be effective 2, 3, 4.
• Dextrose 50% (D50) is often administered with insulin to prevent hypoglycemia, with a typical dose of 25-50 grams 2, 5.
• Some studies suggest that a prolonged infusion of dextrose 10% (D10) may be a safe and effective alternative to D50 bolus for hypoglycemia prevention 5.
• The choice of insulin dose and dextrose administration method may depend on patient-specific factors, such as weight, glucose level, and renal function 6, 3.

Insulin Dosing Strategies

• A study comparing reduced dose (5 units) and conventional dose (10 units) insulin found no significant difference in potassium reduction between the groups, but conventional dose insulin may be more effective at higher baseline serum potassium levels 4.
• Another study found that a weight-based insulin dose of 0.1 units/kg was associated with a lower risk of hypoglycemia and similar potassium reduction compared to a fixed dose of 10 units 3.
• A retrospective analysis of insulin dosing strategies found that greater weight-based insulin dose was a significant predictor of hypoglycemia, while higher pre-insulin glucose levels were protective 6.

Dextrose Administration

• A study comparing D50 bolus and D10 infusion found no difference in incidence of hypoglycemia between the two groups, suggesting that D10 infusion may be a viable alternative to D50 bolus 5.
• Another study found that administering dextrose 50 g instead of 25 g, or administering dextrose as a prolonged infusion instead of a rapid intravenous bolus, may reduce the risk of hypoglycemia 2.