UMEM Educational Pearls

Category: Pharmacology & Therapeutics

Title: Insulin for Hyperkalemia

Keywords: Insulin, Hyperkalemia, Dextrose (PubMed Search)

Posted: 11/6/2017 by Wesley Oliver (Updated: 12/11/2017)
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Strategies for Hyperkalemia Management

Stabilize cardiac membrane

Calcium gluconate

Intracellular movement in skeletal muscles

Albuterol

Sodium Bicarbonate

Insulin

Potassium excretion

Loop Diuretics

Kayexalate

Patiromer (chronic use only)

Potassium removal

Dialysis

 

Insulin mechanism of action for hyperkalemia:

· Binds to skeletal muscle receptors

· Increased activity of the sodium-potassium adenosine triphosphatase and glucose transporter GLUT4

· Glycemic response occurs at lower levels of insulin

· Potassium transport activity increases as insulin levels increase

Patients with insulin resistance due to type-2 diabetes do not become resistant to the kalemic effects of insulin.

 

Hypoglycemia following insulin administration for hyperkalemia:

· Occurs 1-3 hours post dose, even with initial bolus of dextrose

· The amount of glucose is insufficient to replace the glucose utilized in response to the administered dose of insulin

· Insulin’s half-life is increased in ESRD leading to longer duration of action

 

A systematic review of 11 studies regarding insulin dosing for hyperkalemia:

· 22 patients (18%) experienced hypoglycemia

· Studies that only gave 25 grams (1 amp) of dextrose had the highest incidence of hypoglycemia (30%)

 

Tips:

· Consider insulin dose reduction in patients with renal failure

· Use an order set to ensure patients receive appropriate POC glucose monitoring to detect delayed onset of hypoglycemia

· Dextrose 50% (25 grams) should be given to all patients with pre-insulin BG <350 mg/dL

Subsequent PRN dextrose 50% (25 grams) should be used to maintain BG >100 mg/dL after insulin administration

References

References:

1. Sterns RH, Grieff M, Bernstein PL. Treatment of hyperkalemia: something old, something new. Kidney International 2016;89(3):5460554.

2. Harel Z, Kamel KS (2016) Optimal Dose and Method of Administration of Intravenous Insulin in the Management of Emergency Hyperkalemia: A Systematic Review. PLoS ONE 11(5): e0154963. doi:10.1371/journal.pone.0154963