What is the treatment for hyperkalemia?

Treatment for Hyperkalemia

For severe hyperkalemia (≥6.5 mEq/L) or any ECG changes, immediately administer IV calcium chloride 10%: 5-10 mL over 2-5 minutes for cardiac protection, followed simultaneously by insulin 10 units with 25g glucose and nebulized albuterol 10-20 mg, then initiate definitive potassium removal with hemodialysis or loop diuretics depending on renal function. 1, 2

Severity Classification and Initial Assessment

• Mild hyperkalemia: 5.0-5.9 mEq/L 1, 3
• Moderate hyperkalemia: 6.0-6.4 mEq/L 1, 3
• Severe hyperkalemia: ≥6.5 mEq/L (life-threatening) 1, 3

Critical caveat: ECG changes (peaked T waves, flattened P waves, prolonged PR interval, widened QRS) mandate urgent treatment regardless of the potassium level—absent ECG changes do NOT exclude the need for immediate intervention. 1, 4, 5

Before initiating aggressive treatment, exclude pseudo-hyperkalemia from hemolysis or improper sampling by repeating the measurement with appropriate technique or arterial sampling. 1, 3

Step 1: Cardiac Membrane Stabilization (Immediate - Within 1-3 Minutes)

Calcium chloride is preferred over calcium gluconate because it provides more rapid increase in ionized calcium concentration, making it more effective in critically ill patients. 1

• Calcium chloride 10%: 5-10 mL (500-1000 mg) IV over 2-5 minutes 1, 2
• Alternative - Calcium gluconate 10%: 15-30 mL IV over 2-5 minutes 1, 3

Administration considerations:

• Administer calcium chloride through a central venous catheter when possible—extravasation through peripheral IV causes severe tissue injury 1
• Monitor heart rate continuously during administration and stop if symptomatic bradycardia occurs 1
• Effects begin within 1-3 minutes but last only 30-60 minutes 1, 3, 2
• Calcium does NOT lower serum potassium—it only stabilizes cardiac membranes temporarily 1, 3, 2
• If no ECG improvement within 5-10 minutes, repeat the dose 1
• Never administer calcium through the same IV line as sodium bicarbonate—precipitation will occur 1

Step 2: Shift Potassium into Cells (Onset 15-30 Minutes, Duration 4-6 Hours)

Administer all three agents together for maximum effect in severe hyperkalemia: 1

Insulin with Glucose (Most Reliable Agent)

• Standard dose: 10 units regular insulin IV with 25g glucose (50 mL of D50W) over 15-30 minutes 1, 3, 2, 5
• Onset: 15-30 minutes; Duration: 4-6 hours 1, 3
• Never give insulin without glucose—hypoglycemia can be life-threatening 1
• Monitor glucose levels closely; patients with low baseline glucose, no diabetes, female sex, and altered renal function are at higher risk of hypoglycemia 1
• Can be repeated every 4-6 hours if hyperkalemia persists, with careful monitoring of potassium and glucose levels 1

Nebulized Beta-2 Agonist

• Albuterol: 10-20 mg nebulized over 15 minutes 1, 3, 2
• Onset: 15-30 minutes; Duration: 4-6 hours 1
• Can reduce serum potassium by approximately 0.5-1.0 mEq/L 1
• Use alone or to augment the effect of insulin 5

Sodium Bicarbonate (ONLY if Metabolic Acidosis Present)

• Indication: Use ONLY in patients with concurrent metabolic acidosis (pH <7.35, bicarbonate <22 mEq/L) 1, 3, 4
• Dose: 50 mEq IV over 5 minutes 1, 3
• Effects take 30-60 minutes to manifest 3
• Do not use without metabolic acidosis—it is ineffective and wastes time 1, 3

Important warning: These are temporizing measures only—rebound hyperkalemia can occur after 2 hours, so definitive potassium removal must be initiated immediately. 1

Step 3: Eliminate Potassium from Body (Definitive Treatment)

Hemodialysis (Most Effective Method)

• Indication: Severe hyperkalemia (≥6.5 mEq/L), renal failure, oliguria, or hyperkalemia unresponsive to medical management 1, 3, 2
• Most reliable and effective method for potassium removal 3, 5
• Monitor for rebound hyperkalemia within 4-6 hours post-dialysis as intracellular potassium redistributes 1

Loop Diuretics

• Furosemide: 40-80 mg IV 1, 3, 2
• Effective ONLY in patients with adequate renal function 1, 3
• Should be titrated to maintain euvolemia, not primarily for potassium management 1

Potassium Binders (Preferred for Subacute to Chronic Management)

Newer potassium binders are safer and more effective than traditional resins: 1, 3

Sodium Zirconium Cyclosilicate (SZC/Lokelma) - Preferred for Urgent Scenarios

• Acute dosing: 10g three times daily for 48 hours 1, 3
• Maintenance: 5-15g once daily 1, 3
• Onset of action: ~1 hour (fastest available) 1, 3
• Highly selective potassium binding mechanism 1
• Monitor for edema due to sodium content 1

Patiromer (Veltassa) - Preferred for Long-Term Management

• Starting dose: 8.4g once daily with food 1, 3, 6
• Titration: Up to 25.2g daily based on potassium levels 1, 3
• Onset of action: ~7 hours 1, 3
• Separate from other oral medications by at least 3 hours 1
• Causes hypomagnesemia and hypercalcemia—monitor magnesium levels 1
• FDA indication: Treatment of hyperkalemia in adults and pediatric patients ≥12 years 6
• Limitation: Should not be used as emergency treatment due to delayed onset 6

Sodium Polystyrene Sulfonate (Kayexalate) - AVOID

• Should be avoided due to delayed onset, variable efficacy, and risk of bowel necrosis 1, 3
• Associated with intestinal ischemia, colonic necrosis, and doubling of serious GI adverse events 1
• FDA limitation: Should not be used as emergency treatment for life-threatening hyperkalemia due to delayed onset 7

Treatment Algorithm by Severity

Severe Hyperkalemia (K+ ≥6.5 mEq/L or ECG Changes)

1. Immediate: Calcium chloride 10%: 5-10 mL IV over 2-5 minutes 1, 2
2. Within 15 minutes: Insulin 10 units + glucose 25g IV AND albuterol 10-20 mg nebulized 1, 2
3. Add sodium bicarbonate 50 mEq IV ONLY if metabolic acidosis present 1, 2
4. Definitive removal: Hemodialysis (preferred) or furosemide 40-80 mg IV if adequate renal function 1, 2
5. Temporarily discontinue or reduce RAAS inhibitors until K+ <5.0 mEq/L 1, 3
6. Initiate potassium binder (SZC or patiromer) once K+ <5.5 mEq/L to prevent recurrence 1

Moderate Hyperkalemia (K+ 6.0-6.4 mEq/L Without ECG Changes)

1. Intracellular shift: Insulin/glucose AND albuterol 1, 2
2. Potassium removal: Loop diuretics (if adequate renal function) or potassium binders 1, 2
3. Review and adjust contributing medications 1, 3
4. Consider initiating patiromer or SZC for chronic management 1, 3

Mild Hyperkalemia (K+ 5.0-5.9 mEq/L)

1. Review and discontinue offending medications: NSAIDs, trimethoprim, heparin, beta-blockers, potassium supplements, salt substitutes 1, 3, 2
2. Optimize diuretic therapy: Loop or thiazide diuretics if adequate renal function 3
3. Initiate potassium binder for chronic management if recurrent or on RAAS inhibitors 1, 2
4. Maintain RAAS inhibitor therapy—do NOT discontinue 1, 2

Special Population: Patients on RAAS Inhibitors

Critical principle: For patients with cardiovascular disease or proteinuric CKD, maintaining RAAS inhibitors provides mortality benefit and slows disease progression—use potassium binders rather than discontinuing these life-saving medications. 1, 3, 2

K+ 5.0-6.5 mEq/L on RAAS Inhibitors

• Initiate approved potassium-lowering agent (patiromer or SZC) 1, 3, 2
• Maintain RAAS inhibitor therapy unless alternative treatable cause identified 1, 3, 2
• Monitor potassium levels closely 1, 3

K+ >6.5 mEq/L on RAAS Inhibitors

• Temporarily discontinue or reduce RAAS inhibitor 1, 3, 2
• Initiate potassium-lowering agent when levels >5.0 mEq/L 1, 3
• Restart RAAS inhibitor at lower dose once K+ <5.0 mEq/L with concurrent potassium binder therapy 1, 3

Monitoring Protocol

• Check potassium within 1 week of starting or escalating RAAS inhibitors 1, 3
• Reassess 7-10 days after initiating potassium binder therapy 1, 3
• After acute treatment: Monitor potassium every 2-4 hours initially, especially if initial K+ >6.5 mEq/L 1
• High-risk patients (CKD, heart failure, diabetes) require more frequent monitoring 3
• Monitor magnesium levels in patients on patiromer to detect hypomagnesemia 1

Critical Pitfalls to Avoid

• Never delay treatment while waiting for repeat labs if ECG changes are present—ECG changes indicate urgent need regardless of exact potassium value 1, 3
• Never rely solely on ECG findings—they are highly variable and less sensitive than laboratory tests 3
• Never use sodium bicarbonate without metabolic acidosis—it is ineffective without acidosis 1, 3
• Never give insulin without glucose—hypoglycemia can be life-threatening 1
• Never permanently discontinue RAAS inhibitors in patients with cardiovascular disease or proteinuric CKD—use potassium binders instead 1, 3, 2
• Remember that calcium, insulin, and beta-agonists do NOT remove potassium from the body—they only temporize, requiring definitive removal strategies 1, 3
• Avoid sodium polystyrene sulfonate due to serious safety concerns including bowel necrosis 1, 3

Medications to Review and Adjust

Priority medications contributing to hyperkalemia: 1, 3

• RAAS inhibitors (ACE inhibitors, ARBs, mineralocorticoid antagonists)
• Potassium-sparing diuretics (spironolactone, amiloride, triamterene)
• NSAIDs
• Trimethoprim
• Heparin
• Beta-blockers
• Potassium supplements
• Salt substitutes (high potassium content)

The triple combination of ACE inhibitor + ARB + MRA is NOT recommended due to excessive hyperkalemia risk. 1