What is the treatment for hyperkalemia?

Treatment of Hyperkalemia

For severe hyperkalemia (K+ ≥6.5 mEq/L or any ECG changes), immediately administer IV calcium chloride 10%: 5-10 mL over 2-5 minutes to stabilize cardiac membranes, followed simultaneously by insulin 10 units with 25g glucose and nebulized albuterol 10-20 mg, then initiate definitive potassium removal with loop diuretics or hemodialysis. 1, 2, 3

Assessment and Classification

Severity Definitions:

• Mild hyperkalemia: 5.0-5.9 mEq/L 1, 2
• Moderate hyperkalemia: 6.0-6.4 mEq/L 1, 2
• Severe hyperkalemia: ≥6.5 mEq/L (life-threatening) 1, 2

Critical caveat: ECG changes (peaked T waves, flattened P waves, prolonged PR interval, widened QRS) mandate urgent treatment regardless of the absolute potassium value. 1, 2 However, absent or atypical ECG changes do not exclude the necessity for immediate intervention—ECG findings are highly variable and less sensitive than laboratory tests. 2, 4

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

Administer IV calcium immediately if K+ ≥6.5 mEq/L OR any ECG changes are present:

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

Key points:

• Onset within 1-3 minutes, but effects last only 30-60 minutes 1, 2, 3
• Calcium does NOT lower serum potassium—it only temporarily stabilizes cardiac membranes 1, 2, 3
• Monitor ECG continuously during administration 2
• If no ECG improvement within 5-10 minutes, repeat the dose 2
• Never delay calcium while waiting for repeat labs if ECG changes are present 2
• Administer through central line when possible due to tissue injury risk with extravasation 1
• Never give calcium through the same IV line as sodium bicarbonate (precipitation occurs) 2

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

Administer all three agents together for maximum effect:

Insulin with Glucose (First-line)

• Standard dose: 10 units regular insulin IV with 25g glucose (50 mL of D50W) over 15-30 minutes 1, 2, 3
• Monitor glucose closely to prevent hypoglycemia 2
• Can be repeated every 4-6 hours if hyperkalemia persists 2
• Never give insulin without glucose—hypoglycemia can be life-threatening 2

Nebulized Beta-2 Agonist (Adjunctive)

• Albuterol: 10-20 mg nebulized over 15 minutes 1, 2, 3
• Effects last 2-4 hours 2
• Use in combination with insulin/glucose for additive effect 1, 2

Sodium Bicarbonate (Only if Metabolic Acidosis Present)

• Dose: 50 mEq IV over 5 minutes 1, 2
• Only use if pH <7.35 and bicarbonate <22 mEq/L 1, 2
• Effects take 30-60 minutes to manifest 2
• Do not use without concurrent metabolic acidosis—it is ineffective and wastes time 2

Critical warning: These are temporizing measures only—rebound hyperkalemia can occur within 2-4 hours. 1, 2 Failure to initiate concurrent potassium removal will result in recurrent life-threatening arrhythmias. 2

Step 3: Eliminate Potassium from Body (Definitive Treatment)

For Acute Management (Hours to Days)

Loop Diuretics (if adequate renal function):

• Furosemide: 40-80 mg IV 1, 2, 3
• Effective only if eGFR adequate 1, 2
• Titrate to maintain euvolemia, not primarily for potassium management 2

Hemodialysis (most effective method):

• Most reliable for severe hyperkalemia, especially with renal failure 1, 2, 3
• Reserved for severe cases unresponsive to medical management, oliguria, or ESRD 2
• Monitor for rebound hyperkalemia 4-6 hours post-dialysis 2

For Chronic Management (Days to Weeks)

Newer Potassium Binders (Preferred):

Sodium zirconium cyclosilicate (SZC/Lokelma):

• Acute dosing: 10g three times daily for 48 hours 1, 2
• Maintenance: 5-15g once daily 1, 2
• Onset of action: ~1 hour (suitable for urgent outpatient scenarios) 2

Patiromer (Veltassa):

• Starting dose: 8.4g once daily with food 1, 2
• Titrate up to 25.2g daily based on potassium response 2
• Onset of action: ~7 hours 2
• Must separate from other oral medications by at least 3 hours 2
• Monitor magnesium levels (can cause hypomagnesemia) 2

Sodium polystyrene sulfonate (Kayexalate) - AVOID:

• Not recommended for acute management due to delayed onset, limited efficacy, and risk of bowel necrosis 2, 5
• FDA label states it should NOT be used as emergency treatment 5

Treatment Algorithm by Severity

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

1. Immediate (0-5 minutes): Calcium chloride 10%: 5-10 mL IV over 2-5 minutes 1, 2, 3
2. Within 15 minutes: Insulin 10 units + glucose 25g IV AND albuterol 10-20 mg nebulized 1, 2, 3
3. If metabolic acidosis: Add sodium bicarbonate 50 mEq IV 1, 2
4. Definitive removal: Loop diuretics (if adequate renal function) OR hemodialysis 1, 2, 3
5. Medication review: Temporarily discontinue or reduce RAAS inhibitors, NSAIDs, potassium-sparing diuretics 2

Moderate Hyperkalemia (K+ 6.0-6.4 mEq/L, No ECG Changes)

1. Intracellular shift: Insulin/glucose AND albuterol 1, 2, 3
2. Potassium removal: Loop diuretics OR initiate potassium binder 1, 2, 3
3. Medication review: Reduce RAAS inhibitor dose by 50% 2

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

1. Review and discontinue: Potassium supplements, salt substitutes, NSAIDs, trimethoprim, heparin 1, 2, 3
2. Initiate potassium binder: Patiromer or SZC for chronic management 1, 2, 3
3. Maintain RAAS inhibitors: Do NOT discontinue—use potassium binders to enable continuation 1, 2, 3
4. Loop diuretics: Consider if adequate renal function 2

Special Population: Patients on RAAS Inhibitors

For chronic hyperkalemia >5.0 mEq/L in patients requiring RAAS inhibitors (ACE inhibitors, ARBs, MRAs):

• K+ 5.0-6.5 mEq/L: Initiate patiromer or SZC while maintaining RAAS inhibitor therapy 1, 2, 3
• K+ >6.5 mEq/L: Temporarily discontinue or reduce RAAS inhibitor, initiate potassium binder, restart RAAS inhibitor at lower dose once K+ <5.0 mEq/L 1, 2

Critical principle: Patients with cardiovascular disease, heart failure, or proteinuric CKD should NOT permanently discontinue RAAS inhibitors due to hyperkalemia—these medications provide mortality benefit and slow disease progression. 1, 2 Use potassium binders to enable continuation of life-saving therapy. 1, 2

Monitoring Protocol

• Check potassium within 1 week of starting or escalating RAAS inhibitors 2
• Reassess 7-10 days after initiating potassium binder therapy 2
• Monitor every 2-4 hours after acute treatment until stable 2
• High-risk patients (CKD, diabetes, heart failure, history of hyperkalemia) require more frequent monitoring 2
• Monitor magnesium levels in patients on patiromer 2

Critical Pitfalls to Avoid

• Never rely solely on ECG findings—they are highly variable and less sensitive than laboratory tests 2
• Never use sodium bicarbonate without metabolic acidosis—it is ineffective 1, 2
• Never give insulin without glucose—hypoglycemia is life-threatening 2
• Never delay calcium if ECG changes present—do not wait for repeat labs 2
• Remember calcium, insulin, and beta-agonists do NOT remove potassium—they only temporize 1, 2, 3
• Never permanently discontinue RAAS inhibitors in cardiovascular disease—use potassium binders instead 1, 2