From the Guidelines
Hyperkalemia treatment should prioritize calcium gluconate administration to stabilize cardiac membranes, followed by insulin and glucose to drive potassium into cells, and then definitive removal of potassium using sodium polystyrene sulfonate, patiromer, or sodium zirconium cyclosilicate, as supported by the most recent evidence from 1 and 1.
Treatment Approaches
The management of hyperkalemia depends on the severity of the condition and the presence of electrocardiographic changes or muscle weakness. For mild hyperkalemia, dietary restriction and discontinuation of potassium-raising medications may be sufficient. However, for moderate to severe hyperkalemia, more aggressive interventions are necessary.
Key Interventions
- Calcium gluconate: Administered intravenously to rapidly stabilize cardiac membranes and prevent arrhythmias, as recommended by 1 and 1.
- Insulin and glucose: Given intravenously to drive potassium into cells, lowering serum levels within 15-30 minutes, as supported by 1 and 1.
- Inhaled beta-2 agonists: Such as albuterol, which also shift potassium intracellularly, as mentioned in 1 and 1.
- Sodium bicarbonate: May help in acidotic patients, as noted in 1 and 1.
- Definitive removal of potassium: Using sodium polystyrene sulfonate, patiromer, or sodium zirconium cyclosilicate, as recommended by 1, 1, and 1.
Additional Considerations
- Loop diuretics, such as furosemide, can enhance renal potassium excretion in patients with adequate kidney function, as mentioned in 1 and 1.
- Hemodialysis provides rapid and effective potassium removal in life-threatening cases or renal failure, as supported by 1 and 1.
- Continuous cardiac monitoring and follow-up potassium measurements are essential during treatment to ensure normalization of levels and guide ongoing management, as emphasized by 1 and 1.
From the FDA Drug Label
1 INDICATIONS AND USAGE Sodium Polystyrene Sulfonate Powder, for Suspension is indicated for the treatment of hyperkalemia.
Treatment for hyperkalemia includes the use of Sodium Polystyrene Sulfonate Powder, for Suspension.
- However, it is noted that this treatment should not be used as an emergency treatment for life-threatening hyperkalemia due to its delayed onset of action 2.
From the Research
Treatment Options for Hyperkalemia
- Membrane stabilization using calcium gluconate 10% dosed 10 mL intravenously, unless the patient is in cardiac arrest, in which case 10 mL calcium chloride is warranted 3
- Shifting potassium from extracellular to intracellular stores using beta-agonists and intravenous insulin, with some experts recommending the use of synthetic short-acting insulins rather than regular insulin 3
- Promoting potassium excretion through dialysis, loop and thiazide diuretics, and new medications such as patiromer and sodium zirconium cyclosilicate 3, 4, 5
Emergency Interventions
- Inhaled beta-agonists, nebulised beta-agonists, and intravenous insulin-and-glucose are effective in treating hyperkalemia, with the combination of nebulised beta agonists with IV insulin-and-glucose being more effective than either alone 6
- Dialysis is an effective means of removing excess potassium 6
- IV calcium is effective in treating arrhythmias associated with hyperkalemia 6
New Therapies
- Patiromer and sodium zirconium cyclosilicate are new oral potassium-binding agents that show promise in the management of hyperkalemia 4, 5, 7
- These agents may allow for a less restrictive potassium diet and lower RAASi discontinuation rates 5
Management Strategies
- Medical management of acute hyperkalemia revolves around three strategies: stabilizing the myocardium, intracellular shifting of serum potassium, and enhancing elimination of total body potassium via urinary or fecal excretion 7
- High-quality evidence demonstrating efficacy is lacking for many medications, and more research is necessary to establish optimal dosing strategies to manage hyperkalemia in the acute setting 7