Hyperkalemia medical therapy: Difference between revisions

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Revision as of 22:30, 6 July 2018

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-In-Chief: Priyamvada Singh, M.B.B.S. [2]

Overview

When arrhythmias occur, or when potassium levels exceed 6.5 mmol/l, emergency lowering of potassium levels is mandated. Several agents are used to lower potassium levels. Choice depends on the degree and cause of the hyperkalemia, and other aspects of the patient's condition.

Medical Therapy

Calcium supplementation (calcium gluconate 10% (10ml), preferably through a central venous catheter as the calcium may cause phlebitis) does not lower potassium but decreases myocardial excitability, protecting against life threatening arrhythmias.
Magnesium sulfate is used to stabilize cardiac membrane in cases of hyperkalemia due to digoxin toxicity and hyperkalemia in hypercalcemic states.
Insulin (e.g. intravenous injection of 10-15u of (short acting) insulin (e.g. Actrapid) {along with 50ml of 50% dextrose to prevent hypoglycemia}) will lead to a shift of potassium ions into cells, secondary to increased activity of the sodium-potassium ATPase.
Bicarbonate therapy (e.g. 1 ampule (45mEq) infused over 5 minutes) is effective in cases of metabolic acidosis. The bicarbonate ion will stimulate an exchange of cellular H⁺ for Na⁺, thus leading to stimulation of the sodium-potassium ATPase.
Salbutamol (albuterol, Ventolin^®) is a β₂-selective catacholamine that is administered by nebuliser (e.g. 10-20 mg). This drug promotes movement of K into cells, lowering the blood levels.
Polystyrene sulfonate (Calcium Resonium, Kayexalate) is a binding resin that binds K within the intestine and removes it from the body by defecation. Calcium Resonium (15g three times a day in water) can be given by mouth. Kayexelate can be given by mouth or as an enema. In both cases, the resin absorbs K within the intestine and carries it out of the body by defecation. This medication may cause diarrhea and takes a lot of time to lower the potassium levels.
Refractory or severe cases may need dialysis to remove the potassium from the circulation.
Preventing recurrence of hyperkalemia typically involves reduction of dietary potassium, removal of an offending medication, and/or the addition of a diuretic (such as furosemide (Lasix^®) or hydrochlorothiazide).
Patiromer anion is a potassium binding ion cation exchange polymer that increases the gastrointestinal excretion of potassium (it is available in 8.4, 16.8, and 25.2 grams of powder in packets to be administered once daily). Patiromer should not be used as an emergency treatment for life-threatening hyperkalemia because of its delayed onset of action.

Contraindicated medications

Hyperkalemia is considered a relative contraindication to the use of the following medications:

Hyperkalemia (Serum potassium >5.5 mEq/L) is considered an absolute contraindication to the use of the following medications:

Practical approach to treat Hyperkalemia

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 ==Medical Therapy==
 * [[Calcium]] supplementation (calcium gluconate 10% (10ml), preferably through a [[central venous catheter]] as the calcium may cause [[phlebitis]]) does not lower potassium but decreases [[myocardium|myocardial]] excitability, protecting against life threatening [[arrhythmias]].
+* Magnesium sulfate is used to stabilize cardiac membrane in cases of hyperkalemia due to digoxin toxicity and hyperkalemia in hypercalcemic states.
 * [[Insulin]] (e.g. intravenous injection of 10-15u of (short acting) insulin (e.g. Actrapid) {along with 50ml of 50% dextrose to prevent hypoglycemia}) will lead to a shift of potassium ions into cells, secondary to increased activity of the [[sodium-potassium ATPase]].
 * [[Bicarbonate]] therapy (e.g. 1 ampule (45mEq) infused over 5 minutes) is effective in cases of metabolic acidosis.  The bicarbonate ion will stimulate an exchange of cellular H<sup>+</sup> for Na<sup>+</sup>, thus leading to stimulation of the [[sodium-potassium ATPase]].
 * [[Salbutamol]] (albuterol, Ventolin<sup>®</sup>) is a β<sub>2</sub>-selective catacholamine that is administered by nebuliser (e.g. 10-20 mg).  This drug promotes movement of K into cells, lowering the blood levels.
-* [[Polystyrene sulfonate]] (Calcium Resonium, Kayexalate) is a binding resin that binds K within the intestine and removes it from the body by defecation. Calcium Resonium (15g three times a day in water) can be given by mouth. Kayexelate can be given by mouth or as an [[enema]]. In both cases, the resin absorbs K within the intestine and carries it out of the body by [[defecation]].  This medication may cause diarrhea.
+* [[Polystyrene sulfonate]] (Calcium Resonium, Kayexalate) is a binding resin that binds K within the intestine and removes it from the body by defecation. Calcium Resonium (15g three times a day in water) can be given by mouth. Kayexelate can be given by mouth or as an [[enema]]. In both cases, the resin absorbs K within the intestine and carries it out of the body by [[defecation]].  This medication may cause diarrhea and takes a lot of time to lower the potassium levels.
 * Refractory or severe cases may need [[dialysis]] to remove the potassium from the circulation.
 * Preventing recurrence of hyperkalemia typically involves reduction of dietary potassium, removal of an offending medication, and/or the addition of a [[diuretic]] (such as [[furosemide]] (Lasix<sup>®</sup>) or [[hydrochlorothiazide]]).
@@ Line 24: / Line 25: @@
 {{MedCondContrAbs|MedCond = Hyperkalemia (Serum potassium >5.5 mEq/L)|Eplerenone|Spironolactone|Hydrochlorothiazide}}
-==Medical Therapy==
+==Practical approach to treat Hyperkalemia==
-*Pharmacologic medical therapy is recommended among patients with [disease subclass 1], [disease subclass 2], and [disease subclass 3].
-*Pharmacologic medical therapies for [disease name] include (either) [therapy 1], [therapy 2], and/or [therapy 3].
-*Empiric therapy for [disease name] depends on [disease factor 1] and [disease factor 2].
-*Patients with [disease subclass 1] are treated with [therapy 1], whereas patients with [disease subclass 2] are treated with [therapy 2].
-===Disease Name===
-* '''1 Stage 1 - Name of stage'''
-** 1.1 '''Specific Organ system involved 1'''
-*** 1.1.1 '''Adult'''
-**** Preferred regimen (1): [[drug name]] 100 mg PO q12h for 10-21 days '''(Contraindications/specific instructions)'''
-**** Preferred regimen (2): [[drug name]] 500 mg PO q8h for 14-21 days
-**** Preferred regimen (3): [[drug name]] 500 mg q12h for 14-21 days
-**** Alternative regimen (1): [[drug name]] 500 mg PO q6h for 7–10 days
-**** Alternative regimen (2): [[drug name]] 500 mg PO q12h for 14–21 days
-**** Alternative regimen (3): [[drug name]] 500 mg PO q6h for 14–21 days
-*** 1.1.2 '''Pediatric'''
-**** 1.1.2.1 (Specific population e.g. '''children < 8 years of age''')
-***** Preferred regimen (1): [[drug name]] 50 mg/kg PO per day q8h (maximum, 500 mg per dose)
-***** Preferred regimen (2): [[drug name]] 30 mg/kg PO per day in 2 divided doses (maximum, 500 mg per dose)
-***** Alternative regimen (1): [[drug name]]10 mg/kg PO q6h (maximum, 500 mg per day)
-***** Alternative regimen (2): [[drug name]] 7.5 mg/kg PO q12h (maximum, 500 mg per dose)
-***** Alternative regimen (3): [[drug name]] 12.5 mg/kg PO q6h (maximum, 500 mg per dose)
-****1.1.2.2 (Specific population e.g. ''''''children < 8 years of age'''''')
-***** Preferred regimen (1): [[drug name]] 4 mg/kg/day PO q12h（maximum, 100 mg per dose）
-***** Alternative regimen (1): [[drug name]] 10 mg/kg PO q6h (maximum, 500 mg per day)
-***** Alternative regimen (2): [[drug name]] 7.5 mg/kg PO q12h (maximum, 500 mg per dose)
-***** Alternative regimen (3): [[drug name]] 12.5 mg/kg PO q6h (maximum, 500 mg per dose)
-** 1.2 '''Specific Organ system involved 2'''
-*** 1.2.1 '''Adult'''
-**** Preferred regimen (1): [[drug name]] 500 mg PO q8h
-*** 1.2.2  '''Pediatric'''
-**** Preferred regimen (1): [[drug name]] 50 mg/kg/day PO q8h (maximum, 500 mg per dose)
-* 2 '''Stage 2 - Name of stage'''
-** 2.1 '''Specific Organ system involved 1 '''
-**: '''Note (1):'''
-**: '''Note (2)''':
-**: '''Note (3):'''
-*** 2.1.1 '''Adult'''
-**** Parenteral regimen
-***** Preferred regimen (1): [[drug name]] 2 g IV q24h for 14 (14–21) days
-***** Alternative regimen (1): [[drug name]] 2 g IV q8h for 14 (14–21) days
-***** Alternative regimen (2): [[drug name]] 18–24 MU/day IV q4h for 14 (14–21) days
-**** Oral regimen
-***** Preferred regimen (1): [[drug name]] 500 mg PO q8h for 14 (14–21) days
-***** Preferred regimen (2): [[drug name]] 100 mg PO q12h for 14 (14–21) days
-***** Preferred regimen (3): [[drug name]] 500 mg PO q12h for 14 (14–21) days
-***** Alternative regimen (1): [[drug name]] 500 mg PO q6h for 7–10 days
-***** Alternative regimen (2): [[drug name]] 500 mg PO q12h for 14–21 days
-***** Alternative regimen (3):[[drug name]] 500 mg PO q6h for 14–21 days
-*** 2.1.2 '''Pediatric'''
-**** Parenteral regimen
-***** Preferred regimen (1): [[drug name]] 50–75 mg/kg IV q24h for 14 (14–21) days (maximum, 2 g)
-***** Alternative regimen (1): [[drug name]] 150–200 mg/kg/day IV q6–8h for 14 (14–21) days (maximum, 6 g per day)
-***** Alternative regimen (2):  [[drug name]] 200,000–400,000 U/kg/day IV q4h for 14 (14–21) days (maximum, 18–24 million U per day) ''''''(Contraindications/specific instructions)''''''
-**** Oral regimen
-***** Preferred regimen (1):  [[drug name]] 50 mg/kg/day PO q8h for 14 (14–21) days  (maximum, 500 mg per dose)
-***** Preferred regimen (2): [[drug name]] '''(for children aged ≥ 8 years)''' 4 mg/kg/day PO q12h for 14 (14–21) days (maximum, 100 mg per dose)
-***** Preferred regimen (3): [[drug name]] 30 mg/kg/day PO q12h for 14 (14–21) days  (maximum, 500 mg per dose)
-***** Alternative regimen (1):  [[drug name]] 10 mg/kg PO q6h 7–10 days  (maximum, 500 mg per day)
-***** Alternative regimen (2): [[drug name]] 7.5 mg/kg PO q12h for 14–21 days  (maximum, 500 mg per dose)
-***** Alternative regimen (3): [[drug name]] 12.5 mg/kg PO q6h for 14–21 days  (maximum,500 mg per dose)
-** 2.2  '<nowiki/>'''''Other Organ system involved 2''''''
-**: '''Note (1):'''
-**: '''Note (2)''':
-**: '''Note (3):'''
-*** 2.2.1 '''Adult'''
-**** Parenteral regimen
-***** Preferred regimen (1): [[drug name]] 2 g IV q24h for 14 (14–21) days
-***** Alternative regimen (1): [[drug name]] 2 g IV q8h for 14 (14–21) days
-***** Alternative regimen (2): [[drug name]] 18–24 MU/day IV q4h for 14 (14–21) days
-**** Oral regimen
-***** Preferred regimen (1): [[drug name]] 500 mg PO q8h for 14 (14–21) days
-***** Preferred regimen (2): [[drug name]] 100 mg PO q12h for 14 (14–21) days
-***** Preferred regimen (3): [[drug name]] 500 mg PO q12h for 14 (14–21) days
-***** Alternative regimen (1): [[drug name]] 500 mg PO q6h for 7–10 days
-***** Alternative regimen (2): [[drug name]] 500 mg PO q12h for 14–21 days
-***** Alternative regimen (3):[[drug name]] 500 mg PO q6h for 14–21 days
-*** 2.2.2 '''Pediatric'''
-**** Parenteral regimen
-***** Preferred regimen (1): [[drug name]] 50–75 mg/kg IV q24h for 14 (14–21) days (maximum, 2 g)
-***** Alternative regimen (1): [[drug name]] 150–200 mg/kg/day IV q6–8h for 14 (14–21) days (maximum, 6 g per day)
-***** Alternative regimen (2):  [[drug name]] 200,000–400,000 U/kg/day IV q4h for 14 (14–21) days (maximum, 18–24 million U per day)
-**** Oral regimen
-***** Preferred regimen (1):  [[drug name]] 50 mg/kg/day PO q8h for 14 (14–21) days  (maximum, 500 mg per dose)
-***** Preferred regimen (2): [[drug name]] 4 mg/kg/day PO q12h for 14 (14–21) days (maximum, 100 mg per dose)
-***** Preferred regimen (3): [[drug name]] 30 mg/kg/day PO q12h for 14 (14–21) days  (maximum, 500 mg per dose)
-***** Alternative regimen (1):  [[drug name]] 10 mg/kg PO q6h 7–10 days  (maximum, 500 mg per day)
-***** Alternative regimen (2): [[drug name]] 7.5 mg/kg PO q12h for 14–21 days  (maximum, 500 mg per dose)
-***** Alternative regimen (3): [[drug name]] 12.5 mg/kg PO q6h for 14–21 days  (maximum,500 mg per dose)
-==References==
-{{reflist|2}}
 [[Category:Potassium]]
@@ Line 129: / Line 36: @@
 [[Category:Intensive care medicine]]
 [[Category:Needs overview]]
-{{WH}}
-{{WS}}