As a critical care pharmacist, both patiromer (Veltassa) and sodium zirconium cyclosilicate (Lokelma) can play a role in managing acute hyperkalemia, often in conjunction with other interventions. Both meds work similarly to sodium polystyrene sulfonate (Kayexalate), by binding potassium in the GI tract. Limited data suggest that potassium lowering is roughly comparable within 24 hours of a single dose of any of these binders. And cost is similar.
But sodium polystyrene sulfonate is poorly tolerated due to bad taste and constipation, plus it carries concerns about bowel necrosis. If a binder is needed, generally lean toward sodium zirconium cyclosilicate. It starts working in about 1 hour, versus 2 hours for sodium polystyrene sulfonate or 4 hours for patiromer. But ensure that binders aren’t used alone for acute life-threatening hyperkalemia, guide a systematic approach...
- Stabilize the heart. Start with IV calcium in patients with potassium 6.5 mEq/L or higher, or EKG changes at any elevated level.
- Shift potassium into cells. Think of regular insulin (Actrapid) 10 units plus 25 grams of 50% dextrose, given IV, as the gold standard. But hypoglycemia is common. Consider strategies to reduce risk. For example, add dextrose 10% at 50 mL/hr for 5 hours after the insulin and dextrose dose for patients at increased risk, such as if baseline blood glucose is less than 125 mg/dL. And monitor closely, such as glucose checks hourly for 6 hours. Consider nebulized albuterol (Ventolin) 10 to 20 mg, about 4 times more than the standard neb dose. Be aware, albuterol may not be effective for some patients, such as those on a nonselective beta-blocker. Hold off on sodium bicarbonate (Na₂HCO₃) unless the patient has metabolic acidosis, since overall data are mixed.
- Remove potassium. Consider adding a binder, AFTER acute meds. And try loop diuretics but expect patients with severe kidney dysfunction to need hemodialysis.
- Review meds. Look for culprits that may raise potassium on the med list, such as an ACEI, ARB or spironolactone, NSAIDs, or trimethoprim. And don’t forget to ask about dietary supplements. See our resource, "Be ready to treat HYPERKALEMIA in hospital", and "Managing chronic hyperkalemia", for more on acute and chronic treatment.
REFERENCES
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Rydell A, Thackrey C, Molki M, Mullins BP. Effectiveness of Patiromer Versus Sodium Zirconium Cyclosilicate for the Management of Acute Hyperkalemia. Ann Pharmacother. Published online November 12, 2023. Available at: https://pubmed.ncbi.nlm.nih.gov/37953506
Sullivan E, Ruegger M, Dunne I, Sutaria N, Towers WF. Comparison of effectiveness and safety of sodium polystyrene sulfonate and sodium zirconium cyclosilicate for treatment of hyperkalemia in hospitalized patients. Am J Health Syst Pharm. 2023;80(18):1238-1246. Available at: https://academic.oup.com/ajhp/article-abstract/80/18/1238/7202061?redirectedFrom=fulltext&login=false
Joyce O, Corpman M. Comparison of Sodium Zirconium Cyclosilicate to Sodium Polystyrene Sulfonate in the Inpatient Management of Acute Hyperkalemia. J Pharm Pract. Published online May 30, 2023. Available at: https://pubmed.ncbi.nlm.nih.gov/37254518
Di Palo KE, Sinnett MJ, Goriacko P. Assessment of Patiromer Monotherapy for Hyperkalemia in an Acute Care Setting. JAMA Netw Open. 2022;5(1):e2145236. Published 2022 Jan 4. Available at: https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2788445
UK Kidney Association. Clinical Practice Guidelines-Treatment of Acute Hyperkalaemia in Adults. October 2023. Available at: https://ukkidney.org/health-professionals/guidelines/treatment-acute-hyperkalaemia-adults
Lindner G, Burdmann EA, Clase CM, et al. Acute hyperkalemia in the emergency department: a summary from a Kidney Disease: Improving Global Outcomes conference. Eur J Emerg Med. 2020;27(5):329-337. Available at: https://pubmed.ncbi.nlm.nih.gov/32852924