What is the algorithm for managing hyperkalemia (elevated potassium levels)?

From the Guidelines

The algorithm for managing hyperkalemia begins with assessing the severity based on potassium levels and ECG changes, and the most recent evidence suggests that for mild hyperkalemia (K+ 5.5-6.0 mEq/L), discontinuing potassium-elevating medications and considering oral potassium binders like patiromer (8.4g) or sodium zirconium cyclosilicate (10g) is the initial step 1. For moderate hyperkalemia (K+ 6.0-6.5 mEq/L), administering calcium gluconate 1g IV over 2-3 minutes to stabilize cardiac membranes, followed by insulin 10 units IV with 50mL of 50% dextrose to shift potassium intracellularly, is recommended 1. Albuterol 10-20mg nebulized and sodium bicarbonate 50mEq IV can also help shift potassium. For severe hyperkalemia (K+ >6.5 mEq/L or with ECG changes), immediately giving calcium gluconate, followed by insulin/dextrose, and considering emergent dialysis is crucial 1. Loop diuretics like furosemide 40-80mg IV can enhance potassium excretion in patients with adequate renal function. Continuous cardiac monitoring is essential during treatment. These interventions work through different mechanisms: calcium antagonizes cardiac effects without lowering potassium levels, insulin drives potassium into cells, and binders or dialysis physically remove potassium from the body. The underlying cause of hyperkalemia must be identified and addressed to prevent recurrence, and recent clinical studies suggest that the newer K+ binders (patiromer sorbitex calcium and sodium zirconium cyclosilicate) may facilitate optimization of RAASi therapy 1.

Some key points to consider in the management of hyperkalemia include:

• Discontinuing potassium-elevating medications
• Using oral potassium binders like patiromer or sodium zirconium cyclosilicate
• Administering calcium gluconate and insulin/dextrose for moderate hyperkalemia
• Considering emergent dialysis for severe hyperkalemia
• Enhancing potassium excretion with loop diuretics in patients with adequate renal function
• Continuous cardiac monitoring during treatment
• Identifying and addressing the underlying cause of hyperkalemia to prevent recurrence
• Optimizing RAASi therapy with newer K+ binders 1.

It is essential to note that the management of hyperkalemia should be individualized, and the frequency of monitoring serum K+ should be increased for patients with chronic kidney disease, diabetes, heart failure, or a history of hyperkalemia, and for those receiving RAASi therapy 1.

From the FDA Drug Label

The primary endpoint in the acute phase was the difference in the exponential rate of change in serum potassium levels during the initial 48 hours of study drug treatment, comparing placebo-treated patients and LOKELMA-treated patients.

The algorithm of hyperkalemia is not explicitly stated in the provided drug label.

• Key points:
  • The study demonstrated the effectiveness of LOKELMA in lowering serum potassium levels in patients with hyperkalemia.
  • The primary endpoint was the difference in the exponential rate of change in serum potassium levels during the initial 48 hours of study drug treatment.
• Treatment:
  • LOKELMA was administered three times daily for the initial 48 hours with meals.
  • The study met its primary endpoint demonstrating a greater reduction in serum potassium levels for the 2.5, and 10 g (three times a day) dose groups compared to the placebo group.
• Patient response:
  • Patients with higher starting potassium levels had a greater response to LOKELMA.
  • LOKELMA was effective in lowering potassium levels in patients with chronic kidney disease, heart failure, diabetes mellitus, and those taking RAAS inhibitor therapy 2

From the Research

Treatment Approach for Hyperkalemia

The treatment of hyperkalemia involves several key steps, including:

• Stabilization of cardiac membranes 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 the use of loop and thiazide diuretics, as well as newer medications such as patiromer and sodium zirconium cyclosilicate 3, 4, 5

Pharmacologic Treatment Options

Several pharmacologic treatment options are available for the management of hyperkalemia, including:

• Sodium polystyrene sulfonate (SPS), which exchanges sodium for potassium in the gastrointestinal tract 4, 5, 6
• Patiromer, a newer potassium binder that has been shown to be effective in reducing serum potassium levels in patients with chronic kidney disease 5, 6
• Sodium zirconium cyclosilicate (SZC), another newer potassium binder that has been shown to be effective in reducing serum potassium levels in patients with hyperkalemia 4, 5, 7
• Calcium polystyrene sulfonate (CPS), which exchanges calcium for potassium in the gastrointestinal tract and has been shown to be effective in the treatment of chronic hyperkalemia 6

Comparative Efficacy of Treatment Options

Studies have compared the efficacy of different treatment options for hyperkalemia, including:

• A retrospective chart review that found similar rates of normokalemia achievement with SZC and SPS in combination with IV insulin for the treatment of acute hyperkalemia 7
• Clinical trials that have demonstrated the efficacy of patiromer and SZC in reducing serum potassium levels in patients with chronic kidney disease 5, 6