What is the dosage of insulin for treating hyperkalemia?

From the Guidelines

For treating hyperkalemia with insulin, administer 0.1 unit/kg of regular insulin intravenously along with 4 grams of glucose per unit of insulin to prevent hypoglycemia, as recommended by the most recent and highest quality study 1. This regimen typically lowers serum potassium by temporarily driving it into cells. The effects of insulin on potassium levels are usually seen within 15-30 minutes and can last for several hours. It is essential to monitor blood glucose levels closely, especially in patients with diabetes or those who are at risk of hypoglycemia, as insulin can cause a significant drop in blood glucose. In patients with severe hyperkalemia, the dose may need to be repeated, and in those with high blood glucose levels, insulin can be given without additional glucose, but with careful monitoring of blood glucose levels. The mechanism of action involves insulin stimulating the Na+/K+-ATPase pump, which helps to drive potassium into cells, providing a temporary solution to manage hyperkalemia. However, it is crucial to address the underlying cause of hyperkalemia to prevent recurrence and potential complications. Monitoring blood glucose every 30-60 minutes for 2-3 hours after administration is necessary to detect delayed hypoglycemia, a common complication of insulin therapy. Key considerations in managing hyperkalemia include:

• Identifying and treating the underlying cause
• Temporizing measures to lower serum potassium, such as insulin and glucose administration
• Monitoring for complications, including hypoglycemia and cardiac arrhythmias
• Considering other treatment options, such as calcium gluconate, beta-agonists, and diuretics, based on the severity of hyperkalemia and the patient's clinical condition, as discussed in recent studies 1.

From the Research

Dosage for Insulin in Hyperkalemia

• The optimal dose of insulin for hyperkalemia is not well established, but several studies provide guidance on its use 2, 3, 4, 5, 6.
• A study published in 2016 found that 10 units of regular insulin administered as a bolus or infusion was effective in lowering serum potassium levels, but the risk of hypoglycemia was significant 3.
• Another study published in 2019 suggested that using 5 units or 0.1 units/kg of insulin instead of 10 units, and administering dextrose 50 g instead of 25 g, could reduce the risk of hypoglycemia 4.
• A 2022 study compared the use of 5 units versus 10 units of intravenous insulin for hyperkalemia in patients with moderate renal dysfunction, and found that 10 units lowered serum potassium significantly more than 5 units, but there was no difference in hypoglycemic events between the two groups 6.
• The 2018 study recommends the use of synthetic short-acting insulins rather than regular insulin, and suggests that dextrose should also be administered to prevent hypoglycemia 2.
• The 2002 study favors an intravenous bolus of 10 units of insulin with 50 ml of 50% glucose alone or in combination with 10-20 mg of albuterol by nebulizer 5.

Administration Methods

• Insulin can be administered as a bolus or infusion, and the choice of method may depend on the severity of hyperkalemia and the patient's individual needs 3, 5.
• The use of a continuous infusion of 20 units of short-acting insulin over 60 minutes may be considered in patients with severe hyperkalemia or marked EKG changes 3.

Monitoring and Prevention of Hypoglycemia

• Patients receiving insulin for hyperkalemia should be monitored for hypoglycemia hourly for at least 4-6 hours after administration 4.
• The risk of hypoglycemia can be reduced by using lower doses of insulin, administering dextrose, and monitoring plasma glucose levels frequently 3, 4, 6.