Hyperkalemia medical therapy

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-In-Chief: Priyamvada Singh, M.B.B.S. [2] Jogeet Singh Sekhon Syed Ahsan Hussain, M.D.[3]

Overview

Treatment of hyperkalemia includes lowering of serum potassium levels, cardiac membrane stabilization and removal of excess potassium from the body.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.Treatment also depends on the cause of hyperkalemia.

Medical Therapy

Pharmacological therapy in hyperkalemia is dependent on serum potassium levels and the development of symptoms.
Therapy 1 is used in hyperkalemic emergency(emergency lowering of serum K+ required) which is :
- Serum potassium level >6.5 mEq/L
- ECG changes present.
- Serum K+ >5.5 mEq/L and patient has severe renal impairment.
Therapy 2 is used when emergency lowering of potassium levels not required:

Medical management

1.Hyperkalemic emergency

1.1. Pharmacotherapy

1.1.1. Cardiac membrane stabilization

Preferred regime:Calcium gluconate 10% 0.5ml/kg IV loading dose.(contraindicated in digoxin toxicity and hypercalcemia)

Alternate regime:Magnesium sulfate 2gm IV over 5 minutes(in digoxin toxicity and hypercalcemia)

1.1.2. Increase potassium shift from extracellular to intracellular spaces

Preferred regime(1):IV insulin with 2.5-5 ml/kg/h 20% dextrose (0.5-1 g/kg/h) with insulin 0.2 units for every gram of glucose administered..

Preferred regime(2):Salbutamol nebulization: 2.5 mg if <25 kg and 5 mg if >25 kg.
Alternate regime:Sodium bicarbonate 8.4%- 1-2 mmol/kg IV over 30-60 min only in cases of acidosis.

1.1.3. Loop diuretics

Preferred regime:Furosemide 40mg IV laoding dose and then 1-2mg/kg/day tillpotassium levels <5.1 mEq/L.

1.2 Renal replacement therapy.

Haemodialysis ( when renal function is impaired)

2.When emergency lowering of serum K+ not required.

2.1. Pharmacotherapy

2.1.1. Gastrointestinal cation exchangers

Preferred regime:Polystyrene sulfonate (Calcium Resonium, Kayexalate) given 1g/kg/ PO till serum k+ <5.1 mEq/L.

2.1.2. Loop diuretics

Preferred regime:Furosemide 40mg/kg PO till serum K+ <5.1 mEq/L.

2.2 Renal replacement therapy

Haemodialysis(when renal function is impaired)

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:

References