Effective Management of Acute Hyperkalemia: Essential Tips for Critical Care Pharmacists

As a critical care pharmacist, it's crucial to manage acute hyperkalemia effectively. Veltassa (Patiromer) and Lokelma (sodium zirconium cyclosilicate) are essential tools in our arsenal, often used alongside other interventions. Let's dive into their roles and benefits.

Both Veltassa and Lokelma work by binding potassium in the GI tract, similar to sodium polystyrene sulfonate (Kayexalate). Data suggest that potassium lowering is comparable within 24 hours of a single dose of any of these binders. Cost is also similar.

However, Kayexalate is poorly tolerated due to bad taste and constipation, and it carries risks of bowel necrosis. Generally, lean toward Lokelma. It starts working in about 1 hour, compared to 2 hours for Kayexalate or 4 hours for Veltassa.

• Ensure binders aren’t used alone for acute life-threatening hyperkalemia. Stabilize the heart with IV calcium in patients with potassium levels of 6.5 mEq/L or higher, or with EKG changes at any elevated level.
• Shift potassium into cells using regular insulin (Actrapid) 10 units plus 25 grams of 50% dextrose IV. This is the gold standard, but hypoglycemia is common. Consider adding dextrose 10% at 50 mL/hr for 5 hours post-dose for high-risk patients.
• Monitor glucose closely, with checks hourly for 6 hours. Consider nebulized albuterol (Ventolin) 10 to 20 mg, about 4 times the standard neb dose. Note that albuterol may not be effective for patients on nonselective beta-blockers.
• Hold off on sodium bicarbonate (Na₂HCO₃) unless the patient has metabolic acidosis, as the data are mixed. Consider adding a potassium binder after acute meds and try loop diuretics. Patients with severe kidney dysfunction may need hemodialysis.
• Review medications for culprits that may raise potassium levels, such as ACE inhibitors, ARBs, spironolactone, NSAIDs, or trimethoprim. Don’t forget to ask about dietary supplements.

Managing acute hyperkalemia requires a systematic approach. By stabilizing the heart, shifting potassium into cells, removing potassium, and reviewing medications, we can improve patient outcomes. Stay vigilant and informed!

Take-home points

Key strategies for managing acute hyperkalemia...

1. Identify the roles of patiromer (Veltassa) and sodium zirconium cyclosilicate (Lokelma) in hyperkalemia management.
2. Understand that both medications work by binding potassium in the GI tract, similar to sodium polystyrene sulfonate (Kayexalate).
3. Recognize that Lokelma starts working faster than Veltassa or Kayexalate, making it a preferable choice in many cases.
4. Stabilize the heart with IV calcium in patients with potassium levels of 6.5 mEq/L or higher, or with EKG changes at any elevated level.
5. Shift potassium into cells using regular insulin (Actrapid) with 50% dextrose IV, and consider additional dextrose for hypoglycemia risk.
6. Remove potassium using loop diuretics or hemodialysis in severe kidney dysfunction cases, and review medications for potential contributors to hyperkalemia.

References

Keywords: Acute hyperkalemia management, Patiromer (Veltassa), Sodium zirconium cyclosilicate (Lokelma), Sodium polystyrene sulfonate (Kayexalate), Potassium binders, Hyperkalemia treatment, IV calcium for hyperkalemia, Insulin and dextrose for potassium shift, Loop diuretics for hyperkalemia, Hemodialysis for kidney dysfunction, Medications raising potassium levels, EKG changes in hyperkalemia, Potassium removal strategies, Critical care pharmacology