From the Guidelines
Hyperkalemia treatment should prioritize immediate stabilization of cardiac membranes with calcium gluconate 10% (10 mL IV over 2-3 minutes) if ECG changes are present, followed by measures to shift potassium intracellularly and remove excess potassium from the body, as recommended by the most recent and highest quality study 1.
Treatment Approach
The treatment of hyperkalemia involves a step-wise approach based on the severity of the condition and the presence of symptoms or ECG changes.
- For mild hyperkalemia (potassium 5.5-6.0 mEq/L), dietary potassium restriction and discontinuation of potassium-sparing medications may suffice.
- For moderate to severe hyperkalemia (>6.0 mEq/L) or when ECG changes are present, more aggressive treatment is needed, starting with calcium gluconate 10% (10 mL IV over 2-3 minutes) to stabilize cardiac membranes, as this does not lower potassium levels but protects the heart while other treatments take effect 1.
Shifting Potassium Intracellularly
To shift potassium intracellularly, insulin (10 units regular insulin IV) with glucose (25-50g IV) can be administered to prevent hypoglycemia, and albuterol nebulizer (10-20 mg) can also drive potassium into cells 1.
Potassium Removal
For potassium removal, sodium polystyrene sulfonate (15-30g orally or 30-50g rectally) can be used, though newer agents like patiromer (8.4-25.2g daily) or sodium zirconium cyclosilicate (10g TID for 48 hours, then 5-10g daily) are more effective and better tolerated 1.
Additional Measures
- Loop diuretics like furosemide (40-80mg IV) enhance renal potassium excretion in patients with adequate kidney function.
- Hemodialysis remains the most effective method for severe or refractory hyperkalemia, especially in patients with kidney failure. After acute management, addressing the underlying cause is essential to prevent recurrence, as highlighted in the management guidelines 1.
From the FDA Drug Label
Sodium polystyrene sulfonate is a potassium binder indicated for the treatment of hyperkalemia Limitation of Use: Sodium polystyrene sulfonate should not be used an emergency treatment for life threatening hyperkalemia because of its delayed onset of action
Treatment of Hyperkalemia: Sodium polystyrene sulfonate is indicated for the treatment of hyperkalemia. However, it should not be used as an emergency treatment for life-threatening hyperkalemia due to its delayed onset of action.
- The average total daily adult dose is 15 g to 60 g, administered as a 15 g dose, one to four times daily orally, or 30 g to 50 g every six hours rectally 2, 2.
- Key Considerations:
- Not for emergency treatment of life-threatening hyperkalemia
- Delayed onset of action
- Monitor for signs of fluid overload, especially in patients sensitive to high sodium intake
- Risk of intestinal necrosis and other serious gastrointestinal events 2
From the Research
Hyperkalemia Treatment Overview
- Hyperkalemia is a common electrolyte disorder that can result in morbidity and mortality if not managed appropriately 3.
- The most severe effect of hyperkalemia includes various cardiac dysrhythmias, which may result in cardiac arrest and death 3.
Treatment Measures
- Treatment includes measures to "stabilize" cardiac membranes, to shift K+ from extracellular to intracellular stores, and to promote K+ excretion 3.
- Calcium gluconate 10% dosed 10 mL intravenously should be provided 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 should be given, and some experts recommend the use of synthetic short-acting insulins rather than regular insulin 3.
- Dextrose should also be administered, as indicated by initial and serial serum glucose measurements 3.
- Dialysis is the most efficient means to enable removal of excess K+ 3.
- Loop and thiazide diuretics can also be useful 3.
Pharmacological Interventions
- Evidence supports treatment with insulin in combination with glucose, inhaled or intravenous salbutamol, or the combination 4.
- No evidence supporting a clinical effect of calcium or bicarbonate for hyperkalaemia was identified 4.
- Sodium polystyrene sulfonate is not efficacious 3, but may be useful in small amounts 5.
- New medications to promote gastrointestinal K+ excretion, which include patiromer and sodium zirconium cyclosilicate, hold promise 3.
- Sodium zirconium cyclosilicate (SZC) demonstrated superior effectiveness in reducing potassium levels and controlling severe hyperkalemia in patients undergoing maintenance HD, compared to calcium polystyrene sulfonate (CPS) 6.
Potassium Binders
- SZC and CPS are indicated for treating hyperkalemia in chronic renal disease 6.
- SZC achieved a higher percentage of patients exhibiting serum potassium levels below 6.0 mmol/L at the 2-week timepoint, compared to CPS 6.
- SZC facilitated more rapid control of serum potassium levels, offering an improved long-term management strategy for chronic hyperkalemia 6.