From the Guidelines
Hyperkalemia is a life-threatening condition that requires immediate treatment, especially in severe cases (>6.5 mEq/L) or when ECG changes are present, with calcium gluconate, insulin, and glucose being the first line of treatment. The management of hyperkalemia involves both acute and long-term strategies. For acute management, calcium gluconate 10% (10 mL IV over 2-3 minutes) should be administered to stabilize cardiac membranes, followed by insulin (10 units regular insulin IV) with glucose (25g dextrose) to shift potassium intracellularly 1. Albuterol nebulization (10-20 mg) can also help lower potassium levels.
Acute Management
- Calcium gluconate 10% (10 mL IV over 2-3 minutes) to stabilize cardiac membranes
- Insulin (10 units regular insulin IV) with glucose (25g dextrose) to shift potassium intracellularly
- Albuterol nebulization (10-20 mg) to help lower potassium levels
- For potassium removal, sodium polystyrene sulfonate (15-30g orally or rectally), patiromer (8.4-16.8g daily), or sodium zirconium cyclosilicate (10g three times daily initially) can be used 1
Long-term Management
- Address underlying causes such as medication review (discontinue potassium-sparing diuretics, ACE inhibitors, NSAIDs)
- Dietary potassium restriction (<2-3g daily)
- Treating any renal dysfunction
- Patients with chronic hyperkalemia may benefit from long-term K+-binding therapy, initiated at the recommended dose and titrated according to serum K+ levels 1
Hyperkalemia is dangerous because excess potassium disrupts the electrical gradient across cell membranes, particularly affecting cardiac conduction, which can lead to life-threatening arrhythmias including ventricular fibrillation and asystole. The frequency of K+ monitoring should be individualized on the basis of patient comorbidities and medications (eg, RAASi), particularly in patients at high risk for development of hyperkalemia 1.
From the FDA Drug Label
1 INDICATIONS AND USAGE Sodium Polystyrene Sulfonate Powder, for Suspension is indicated for the treatment of hyperkalemia.
Limitation of Use: Sodium Polystyrene Sulfonate Powder, for Suspension should not be used as an emergency treatment for life-threatening hyperkalemia because of its delayed onset of action [see Clinical Pharmacology (12.2)].
Hyperkalemia Treatment: Sodium Polystyrene Sulfonate Powder, for Suspension is indicated for the treatment of hyperkalemia. However, it should not be used as an emergency treatment for life-threatening hyperkalemia due to its delayed onset of action 2.
- The average total daily adult dose is 15 g to 60 g, administered as a 15-g dose, one to four times daily 2.
- It is essential to monitor serum potassium during therapy because severe hypokalemia may occur 2.
From the Research
Definition and Causes of Hyperkalemia
- Hyperkalemia is a common electrolyte disorder characterized by an elevated extracellular fluid potassium concentration 3, 4, 5.
- It can result from various medical conditions, such as chronic kidney disease (CKD), diabetes mellitus, and others 5.
- Hyperkalemia can also be caused by reduced potassium excretion, often associated with decreased potassium secretion in the aldosterone-sensitive distal nephron of the kidney 4.
Symptoms and Diagnosis of Hyperkalemia
- Hyperkalemia can be asymptomatic, but it may also be associated with electrocardiogram (ECG) changes and life-threatening cardiac arrhythmias 3, 4.
- The diagnosis of hyperkalemia is typically made through serum clinical laboratory measurement and ECG findings 3, 5.
- A history and physical examination can be beneficial in the diagnosis of hyperkalemia, and certain characteristic ECG findings are associated with the condition 5.
Treatment of Hyperkalemia
- Treatment of hyperkalemia includes measures to stabilize cardiac membranes, shift potassium from extracellular to intracellular stores, and promote potassium excretion 3, 4.
- Calcium gluconate or calcium chloride can be used to stabilize cardiac membranes, while beta-agonists and intravenous insulin can help shift potassium into cells 3, 4, 6.
- Dialysis is the most efficient means of removing excess potassium from the body, and loop and thiazide diuretics can also be useful 3, 6.
- New medications, such as patiromer and sodium zirconium cyclosilicate, can promote gastrointestinal potassium excretion and hold promise for the treatment of hyperkalemia 3, 5.
Management of Hyperkalemia
- Prompt recognition of hyperkalemia and administration of appropriate treatment can prevent serious cardiac complications 4.
- The management of hyperkalemia requires a long-term plan to prevent its recurrence or worsening, including the identification and treatment of underlying causes and the avoidance of medications that can exacerbate the condition 6.
- Clinicians must be aware of the various medications available for the treatment of hyperkalemia, including their benefits and contraindications, in order to provide effective management 5.