Managing CHRONIC hyperkalemia

Recommend a thiazide or loop diuretic for long-term treatment when potassium levels are high over 5 mEq/L....
Abdelwahab Ward, BS Pharm, PharmD

How to manage chronic hyperkalemia? ― Hyperkalemia is a potentially life-threatening metabolic problem caused by inability of the kidneys to excrete potassium. We know ACEIs, ARBs, or aldosterone antagonists (spironolactone, etc) can raise potassium levels especially in chronic kidney disease, etc. Sodium polystyrene sulfonate (Kayexalate, etc) is a potassium binder used for hyperkalemia, but it can raise sodium and cause GI side effects. Patiromer (Veltassa) won't raise sodium, since it exchanges calcium instead of sodium to bind potassium. It's also not likely to cause hypercalcemia and may have fewer GI side effects. Both patiromer (Veltassa) and sodium polystyrene sulfonate (Kayexalate, etc) need to be spaced 6 hours from ALL other oral medications to avoid binding.

Recommend other strategies for chronic hyperkalemia BEFORE suggesting a daily potassium binder. Suggest limiting dietary potassium, such as salt substitutes. Recommend a thiazide or loop diuretic for long-term treatment when potassium levels are high over 5 mEq/L. If appropriate, suggest backing off on medications that raise potassium. For example, consider suggesting a lower spironolactone dose if it's being used with an ACEI or ARB or possibly stopping it.

Suggest saving daily potassium binders for when the benefits of staying on an ACEI, ARB, or aldosterone antagonist outweigh the downsides of the binder and other measures aren't enough. If cost isn't a big concern, lean toward patiromer (Veltassa), since it may have fewer side effects than sodium polystyrene sulfonate. And patiromer has more data showing long-term efficacy and safety, despite widespread use of sodium polystyrene sulfonate. Don't recommend potassium binders alone for ACUTE, severe hyperkalemia because they don't work quickly enough.

References

Abdelwahab Ward, BS Pharm, PharmD