How do I treat hyperkalaemia

Recommended management strategies for hyperkalaemia involve a stepwise approach focused on stabilising cardiac membranes, shifting potassium intracellularly, removing excess potassium, and addressing underlying causes.

Initially, in cases of severe hyperkalaemia or when ECG changes are present, intravenous calcium salts (such as calcium chloride) are administered to stabilise cardiac membranes and reduce the risk of life-threatening arrhythmias ⁵. Concurrently, therapies to shift potassium into cells are used, typically insulin with glucose, which promotes cellular uptake of potassium, thereby lowering serum potassium levels rapidly (Moussavi et al., 2019). Beta-2 agonists and sodium bicarbonate may also be considered in specific clinical contexts (Moussavi et al., 2019; Masi et al., 2025).

Removal of potassium from the body is achieved through several modalities. In acute settings, diuretics may be used if renal function permits. More recently, potassium-binding agents such as sodium zirconium cyclosilicate, patiromer calcium, and calcium polystyrene sulfonate have been employed to enhance gastrointestinal potassium excretion ²,³,⁴. These agents are particularly useful in chronic or recurrent hyperkalaemia and may reduce the need for emergency interventions (Masi et al., 2025).

In patients with renal impairment or those at high risk of hyperkalaemia (e.g., on potassium-sparing diuretics, ACE inhibitors, or ARBs), close monitoring of serum potassium is essential, and medication review should be undertaken to minimise contributing factors ¹. Intravenous fluid therapy should be carefully managed to avoid exacerbating electrolyte imbalances ⁸.

Long-term management includes identifying and treating underlying causes such as renal dysfunction, medication effects, or metabolic disturbances. Dietary potassium intake may need adjustment, but this alone is insufficient for acute correction ¹. In refractory or severe cases, dialysis may be required to remove potassium effectively (Masi et al., 2025).

Summary: Stabilise cardiac membranes with IV calcium, shift potassium intracellularly using insulin and glucose, remove potassium via diuretics or potassium binders, monitor and adjust medications, and treat underlying causes. Use potassium binders like sodium zirconium cyclosilicate or patiromer for chronic management. Dialysis is reserved for severe or refractory cases ¹,²,³,⁴,⁵,⁸ (Moussavi et al., 2019; Masi et al., 2025).