From the Guidelines
For immediate reversal of hyperkalemia, calcium gluconate (10%, 10-20 mL IV over 2-3 minutes) should be administered first to stabilize cardiac membranes if ECG changes are present, as recommended by the most recent and highest quality study 1. This approach prioritizes the protection of the heart from the effects of hyperkalemia, which is crucial for preventing morbidity and mortality. The treatment of hyperkalemia involves several interventions depending on the severity and clinical presentation, including:
- Stabilizing cardiac membranes with calcium gluconate or calcium chloride
- Shifting potassium into cells using insulin and glucose, or beta-2 adrenergic agonists like albuterol
- Removing potassium from the body using loop diuretics, hemodialysis, or potassium-binding resins like sodium polystyrene sulfonate, patiromer, or sodium zirconium cyclosilicate
- Addressing the underlying cause of hyperkalemia, which may involve adjusting medications, dietary changes, or treating underlying medical conditions, as discussed in 1. It is essential to monitor potassium levels closely and adjust treatment accordingly to prevent both hyperkalemia and hypokalemia, as emphasized in 1. The choice of treatment should be guided by the severity of hyperkalemia, the presence of ECG changes, and the patient's renal function, as well as their overall clinical condition, as outlined in 1. By prioritizing the most recent and highest quality evidence, we can ensure that patients with hyperkalemia receive the most effective and safe treatment, minimizing the risk of morbidity and mortality.
From the FDA Drug Label
Sodium Polystyrene Sulfonate Powder, for Suspension is indicated for the treatment of hyperkalemia (1). 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 (1).
- Reversal for hyperkalemia: The drug labels for polystyrene sulfonate (PO) indicate it is used for the treatment of hyperkalemia 2 and 2.
- However, it should not be used as an emergency treatment for life-threatening hyperkalemia due to its delayed onset of action.
- Therefore, for emergency or life-threatening hyperkalemia, other treatments should be considered.
From the Research
Reversal for Hyperkalemia
- Hyperkalemia is a life-threatening condition that requires immediate treatment, which includes measures to stabilize cardiac membranes, shift potassium from extracellular to intracellular stores, and promote potassium excretion 3.
- Treatment options for hyperkalemia include:
- Calcium gluconate 10% dosed 10 mL intravenously for membrane stabilization, unless the patient is in cardiac arrest, in which case 10 mL calcium chloride is warranted 3.
- Beta-agonists and intravenous insulin, with some experts recommending the use of synthetic short-acting insulins rather than regular insulin 3.
- Dextrose administration, as indicated by initial and serial serum glucose measurements 3, 4.
- Dialysis, which is the most efficient means to enable removal of excess potassium 3.
- Loop and thiazide diuretics, which can also be useful 3.
- Insulin and glucose are frequently used to manage patients with hyperkalemia, but hypoglycemia after insulin use is a frequent complication 4.
- Strategies to reduce the risk of hypoglycemia with insulin therapy include using lower doses of insulin, administering dextrose 50 g instead of 25 g, or administering dextrose as a prolonged infusion instead of a rapid intravenous bolus 4.
- A systematic review and meta-analysis found that treatment with insulin in combination with glucose, inhaled or intravenous salbutamol, or the combination reduced potassium levels, but there was no evidence to support a clinical beneficial effect of calcium or bicarbonate for hyperkalemia 5.