What are the treatment options for hyperkalemia?

Treatment of Hyperkalemia

For acute severe hyperkalemia (≥6.5 mEq/L or any ECG changes), immediately administer IV calcium gluconate 15-30 mL over 2-5 minutes for cardiac membrane stabilization, followed simultaneously by insulin 10 units with 25g glucose and nebulized albuterol 10-20 mg to shift potassium intracellularly, then initiate definitive potassium removal with loop diuretics or hemodialysis. 1, 2, 3

Acute Hyperkalemia Management

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

• Administer IV calcium first - this is the most critical intervention for preventing fatal arrhythmias 1, 2
• Calcium gluconate (10%): 15-30 mL IV over 2-5 minutes is the preferred agent for peripheral access 1, 2
• Calcium chloride (10%): 5-10 mL IV over 2-5 minutes provides more rapid ionized calcium increase and is preferred for central access or critically ill patients 1, 2, 3
• Effects begin within 1-3 minutes but last only 30-60 minutes 4, 1
• Critical caveat: Calcium does NOT lower potassium levels - it only temporarily stabilizes cardiac membranes 4, 1, 2
• If no ECG improvement within 5-10 minutes, repeat the same dose 4, 1
• Monitor continuously during administration and stop if symptomatic bradycardia occurs 1

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

• Insulin with glucose: 10 units regular insulin IV with 25g glucose (50 mL D50W) over 15-30 minutes 4, 1, 2, 3
• Nebulized albuterol: 10-20 mg over 15 minutes as adjunctive therapy 4, 1, 2, 3
• Give all three agents together (calcium, insulin/glucose, albuterol) for maximum effect 2
• Sodium bicarbonate 50 mEq IV over 5 minutes ONLY if concurrent metabolic acidosis present (pH <7.35, bicarbonate <22 mEq/L) 4, 1, 2
• Critical pitfall: Always give glucose with insulin - verify baseline glucose and monitor to prevent life-threatening hypoglycemia 1, 2
• These are temporizing measures only - rebound hyperkalemia can occur after 2-4 hours 1, 2

Step 3: Eliminate Potassium from Body (Definitive Treatment)

• Loop diuretics (furosemide 40-80 mg IV) - effective only with adequate renal function (eGFR >30 mL/min) 4, 1, 2, 3
• Hemodialysis - most effective and reliable method for severe hyperkalemia, especially with renal failure, oliguria, or cases refractory to medical management 4, 1, 2, 3
• Newer potassium binders for subacute management:
  • Sodium zirconium cyclosilicate (SZC/Lokelma): 10g three times daily for 48 hours, then 5-15g once daily - onset within 1 hour 4, 2
  • Patiromer (Veltassa): 8.4g once daily with food, titrate up to 25.2g daily - onset approximately 7 hours 4, 2
• Avoid sodium polystyrene sulfonate (Kayexalate) - delayed onset, limited efficacy, and risk of bowel necrosis and intestinal ischemia 4, 2, 5, 6, 7

Chronic Hyperkalemia Management

Medication Review and Optimization

• DO NOT permanently discontinue RAAS inhibitors (ACE inhibitors, ARBs, mineralocorticoid antagonists) in patients with cardiovascular disease, heart failure, or proteinuric CKD - these provide mortality benefit 4, 2
• For potassium 5.0-6.5 mEq/L: Initiate patiromer or SZC while maintaining RAAS inhibitor therapy 4, 2, 3
• For potassium >6.5 mEq/L: Temporarily hold or reduce RAAS inhibitor, initiate potassium binder, restart RAAS inhibitor at lower dose once K+ <5.0 mEq/L 4, 2
• Review and eliminate contributing medications: NSAIDs, trimethoprim, heparin, beta-blockers, potassium-sparing diuretics, potassium supplements, salt substitutes 4, 2

Diuretic Therapy

• Loop or thiazide diuretics promote urinary potassium excretion by stimulating flow to renal collecting ducts 4, 2
• Effectiveness depends on residual kidney function 4
• Fludrocortisone increases potassium excretion but carries risks of fluid retention, hypertension, and vascular injury - use cautiously only when other options exhausted 4, 2

Potassium Binder Selection and Dosing

• Patiromer (Veltassa):

  • Starting dose: 8.4g once daily with food 4, 2
  • Titrate weekly in 8.4g increments up to 25.2g daily based on potassium response 4, 2
  • Separate from other oral medications by at least 3 hours to avoid reduced absorption 2
  • Monitor magnesium levels - can cause hypomagnesemia 2
  • Mechanism: exchanges calcium for potassium in colon 4, 2

• Sodium zirconium cyclosilicate (SZC/Lokelma):

  • Acute phase: 10g three times daily for 48 hours 4, 2
  • Maintenance: 5-15g once daily 4, 2
  • Faster onset (1 hour) makes it suitable for more urgent scenarios 4, 2
  • Monitor for edema due to sodium content 2
  • May improve metabolic acidosis by increasing bicarbonate 2

Monitoring Protocol

• Check potassium within 1 week of starting or escalating RAAS inhibitors 4, 2
• Reassess 7-10 days after initiating or adjusting potassium binder therapy 4, 2
• High-risk patients require more frequent monitoring: CKD, diabetes, heart failure, history of hyperkalemia 4, 2
• For hemodialysis patients: Target predialysis potassium 4.0-5.5 mEq/L 2
• For advanced CKD (stage 4-5): Broader optimal range of 3.3-5.5 mEq/L 2

Critical Pitfalls to Avoid

• Never delay calcium administration while waiting for repeat labs if ECG changes present - ECG changes indicate urgent need regardless of exact potassium value 2
• Never use sodium bicarbonate without metabolic acidosis - it is ineffective and wastes time 4, 1, 2
• Never give insulin without glucose - hypoglycemia can be life-threatening 1, 2
• Never rely solely on ECG findings - they are highly variable and less sensitive than laboratory tests 4, 2
• Remember calcium, insulin, and beta-agonists do NOT remove potassium - they only temporize, requiring definitive removal strategies 4, 1, 2
• Do not use sodium polystyrene sulfonate for acute management - delayed onset and serious GI complications including bowel necrosis 4, 2, 5, 6, 7
• Exclude pseudohyperkalemia from hemolysis or improper sampling before initiating aggressive treatment 1, 2

Special Population Considerations

Patients with CKD

• Maintain RAAS inhibitors aggressively using potassium binders - these drugs slow CKD progression and provide mortality benefit 4, 2
• Loop diuretics effectiveness depends on residual kidney function 4, 2
• Dialysis reserved for severe cases unresponsive to medical management 4, 2

Patients with Heart Failure

• Use potassium binders to enable continuation of life-saving RAAS inhibitor therapy rather than discontinuing 4, 2
• Consider SGLT2 inhibitors to reduce hyperkalemia risk 2
• Reduce mineralocorticoid antagonist dose by 50% at potassium >5.5 mEq/L, then add potassium binder 2

Hemodialysis Patients

• SZC 5g once daily on non-dialysis days is preferred first-line agent 2
• Patiromer 8.4g once daily as second-line, separated from other medications by 3 hours 2
• Target predialysis potassium 4.0-5.5 mEq/L to minimize mortality risk 2
• Consider adjusting dialysate potassium concentration (typically 2.0-3.0 mEq/L) based on trends 2

Team Approach

• Optimal chronic hyperkalemia management involves specialists (cardiologists, nephrologists), primary care physicians, nurses, pharmacists, social workers, and dietitians 4, 2
• Educational initiatives on newer potassium binders are needed for primary care physicians, especially in regions where specialist services may not be readily available 4