Hyperkalemia Protect, Shift, and Eliminate

Transcription

1 Disclosure Michael C. Thomas reports no relevant financial relationships. Lytes Off in Vegas! The Acute Management of Potassium and Calcium Disorders Program Objectives Design a plan to replace and monitor potassium Recommend a comprehensive treatment approach for the patient with hyperkalemia Incorporate knowledge about treatments for calcium disorders d into the therapeutic ti plan for a patient t Hyperkalemia Protect, Shift, and Eliminate Michael C. Thomas, Pharm.D., BCPS Associate Professor South University School of Pharmacy Savannah, GA Session Objectives Identify severe hyperkalemia using laboratory studies and signs/symptoms Design an initial treatment plan to decrease serum potassium Summarize the supporting evidence from clinical i l trials Case CC: LV is a 68-year-old woman (80kg) presented to the ED with weakness HPI: Weakness progressed over several days. Sx started after she started SMX/TMP for a UTI PMH: HTN x 15 years, CKD Stage 3, DM, GERD, OA Medications PTA: lisinopril (new 2 weeks ago), amlodipine, glimepiride, famotidine, celecoxib, aspirin, SMX/TMP (day 3 of 7) Page 1 of 6

2 Case, contd. Talk About It ROS: Per HPI PE: Bilateral weakness 3/5 LE, 4/5 UE ECG: Peaked T waves, prolonged PR, HR 35 Turn to someone next to you and answer the following questions: What are the causes of hyperkalemia in LV? What therapeutic interventions would your recommend if consulted? 133 meq/l 99 meq/l 68 mg/dl 8.4 meq/l 21 meq/l 3.4 mg/dl 157 mg/dl Which of the following likely contributed to hyperkalemia in this case? A. Sulfamethoxazole/Trimethoprim B. Pseudohyperkalemia (RBC hemolysis) C. Acidosis D. Urinary tract infection Renal Failure Causes of Hyperkalemia Endocrine Acidosis Excessive Intake Drugs Hyperkalemia Hemolysis Alfonzo AVM, et al. Resuscitation 2006;70:10 25.; Acker CG, et al. Arch Intern Med 1998;158: Case Causes Medications Lisinopril, celecoxib, sulfamethoxazole/trimethoprim Renal function Stage 3 CKD ClCr ~20mL/min Which of the following likely contributed to hyperkalemia in this case? A. Sulfamethoxazole/Trimethoprim B. Pseudohyperkalemia (RBC hemolysis) C. Acidosis D. Urinary tract infection Page 2 of 6

3 Clinical Manifestations EKG Changes Cardiac Conduction Serum Potassium Neuromuscular Peaked T Waves Rule out EKG changes pseudohyperkalemia Muscle Peaked T waves Severe: serum weakness Widened QRS potassium 6.5 Rarely paralysis Sine wave meq/l Decreased EKG insensitive DTR mEq/L Prolonged PR Segment Khanna A, et al. Am J Med 2009;122: ; Weisberg L. Crit Care Med 2008; ; Shingarev R, et al. Am J Kidney Dis 2010;56: Adapted from: Sood MM, et al. Mayo Clin Proc 2007;82: EKG Changes EKG Changes ST Segment Elevation Sine Wave Pattern meq/l mEq/L mEq/L Loss of P Wave Prolonged QRS Ventricular Fibrillation Asystole Conduction Blocks Widened QRS Adapted from: Sood MM, et al. Mayo Clin Proc 2007;82: Adapted from: Sood MM, et al. Mayo Clin Proc 2007;82: Which of the following would you recommend to treat LV s hyperkalemia? Overview of Treatment Strategies Protect Shift A. Insulin + dextrose + sodium bicarbonate b B. Calcium + insulin + dextrose + albuterol C. Albuterol + sodium polystyrene sulfonate D. Calcium + hemodialysis Eliminate-Renal Eliminate-Dialysis Eliminate-Gut Page 3 of 6

4 Protect Calcium stabilizes myocytes Restores resting membrane potential Serum potassium unchanged Improves electrocardiogram Lack of data Caution with digoxin Calcium Administer if electrocardiogram changes Rapid onset, short duration Gluconate or chloride salt forms Chloride = 3x gluconate Tissue necrosis Severity Dosing 1 gm (10 ml) IV calcium gluconate or calcium chloride Repeat in 5 minutes if needed Cardiac arrest mg (5-10 ml) IV calcium chloride mg (15-30 ml) IV calcium gluconate Bisogno JL, et al. Crit Care Med 1994;22: ; Shingarev R, et al. Am J Kidney Dis 2010; ; Weisberg L, et al. Crit Care Med 2008;36: Weisberg L, et al. Crit Care Med 2008;36: ; Acker CG, et al. Arch Intern Med 1998;158: ; Vanden Hoek TL, et al. Circulation 2010;122:S Shift Insulin + Glucose Shift Insulin + Glucose Limited data Crossover design Serum potassium Absolute decrease meq/l Maximal effect min Hypoglycemia 20-75% ium (meq/l) Serum Potass P<0.05 for all pre and post comparisons Allon 1996 Ngugi 1997 Pre Allon 1990 Post Lens 1989 Na/K ATPase Duration up to 6 hours Insulin > dextrose Dextrose helps prevent hypoglycemia Monitor glucose Omit dextrose if hyperglycemia Cornerstone of therapy Insulin 10 units IV Dextrose 25-50gm IV 2K + 3 Na + Allon M, et al. Am J Kidney Dis 1996;28: ; Ngugi NN, et al., East Afr Med J 1997;73:503 9.; Allon M, et al., Kidney Int 1990;38: ; Lens XM, et al. Nephrol Dial Transplant 1989; Weisberg L, et al. Crit Care Med 2008;36: ; Sood MM, et al. Mayo Clin Proc 2007;82: ; Ahee P, et al. J Accid Emerg Med 2000;17: Shift Sodium Bicarbonate Shift - Beta-agonists Conflicting data Na + 2K + Theory Na/H exchanger Metabolic acidosis H + 3 Na + Na/K ATPase Absolute potassium decrease meq/l Commonly recommended if concomitant metabolic acidosis meq IV um (meq/l) Serum Potassiu Allon 1996 Mocan 1993 Allon 1989 (10mg) P<0.05 for all pre and post comparisons Allon 1989 (20mg) Allon 1990 Pre Post Shingarev R, et al. Am J Kidney Dis 2010; ; Kim HJ. Nephron 1996;72: ; Allon M, et al. Am J Kidney Dis 1996;28: ; Ngugi NN, et al., East Afr Med J 1997;73:503 9.; Vanden Hoek TL, et al. Circulation 2010;122:S ; Allon M, et al. Am J Kidney Dis 1996;28: ; Mocan MZ, et al., Isr J Med Sci 1993;29:39 41.; Allon M, et al. Ann Int Med 1989;110:426 9.; Allon M, et al., Kidney Int 1990;38: Page 4 of 6

5 Shift - Beta-agonists Activity independent of insulin Activates camp which activates Na/K ATPase Absolute changes meq/l Onset: 15 min Duration: 2-4 hours Resistance 12-40% May prevent hypoglycemia 10-20mg nebulized Okay, but don t we use these drugs together? Shingarev R, et al. Am J Kidney Dis 2010; ; Weisburg LS. Crit Care Med 2008;36: ; Ahee P, et al. J Accid Emerg Med 2000;17: Shift - Combinations Shift - Combinations Insulin + glucose + albuterol Magnitude of potassium decrease meq/l More effective than insulin + glucose alone Sodium bicarbonate + albuterol Not different when compared with albuterol alone Magnitude of potassium decrease meq/l Insulin + glucose + sodium bicarbonateb No different when compared with insulin + glucose alone Magnitude of potassium decrease meq/l Insulin + glucose + albuterol l + sodium bicarbonateb More effective than other combinations or single agents Magnitude of potassium decrease 1.7 meq/l Allon M, et al. Am J Kidney Dis 1996;28: ; Mocan MZ, et al., Isr J Med Sci 1993;29:39 41.; Allon M, et al. Ann Int Med 1989;110:426 9.; Allon M, et al., Kidney Int 1990;38: ; Ngugi NN, et al. East Afr Med J 1997;73:503 9.; Kim HJ. Nephron 1996;72: Allon M, et al. Am J Kidney Dis 1996;28: ; Mocan MZ, et al., Isr J Med Sci 1993;29:39 41.; Allon M, et al. Ann Int Med 1989;110:426 9.; Allon M, et al., Kidney Int 1990;38: ; Ngugi NN, et al. East Afr Med J 1997;73:503 9.; Kim HJ. Nephron 1996;72: Eliminate - Gut Eliminate - Renal Sodium polystyrene sulfonate Cation exchange resin Sodium for potassium Colon Rectal or oral administration Delayed onset Sodium load Intestinal necrosis risk Not to be used alone gm PO or PR Theoretical benefit Loop diuretics Assess volume, hemodynamics and renal function Onset: 15min-1hr Duration: 2-4 hours Furosemide 20-80mg IV Kayexalate [package insert]. Sanofi Aventis, 12/2010.; Weisburg LS. Crit Care Med 2008;36: ; Sood MM, et al. Mayo Clin Proc 2007;82: ; Shingarev R, et al. Am J Kidney Dis 2010;56: Hollander Rodriguez JC, et al. Am Fam Physician 2006;73: ; VandednHoek TL, et al. Circulation 2010;122:S Page 5 of 6

6 Eliminate - Hemodialysis Definitive treatment Refractory hyperkalemia Serum potassium decrease meq/l/hr Rate related to blood flow and dialysate potassium concentration Potassium rebound Back to the Case LV treatment Calcium gluconate 1gm intravenously Insulin 10 units intravenously Hypertonic dextrose 25 gm intravenously Albuterol 20mg by nebulizer Sood MM, et al. Mayo Clin Proc 2007;82: ; Weisburg LS. Crit Care Med 2008;36: ; Elliott MJ, et all. CMAJ 2010;182: Back to the Case Severe Hyperkalemia K 6.5 meq/l Outcomes ECG normalized Repeat serum potassium 5.4 meq/l Weakness improved Hospitalized for monitoring Protect IV Calcium Eliminate-Renal No ECG Changes Yes No Renal Failure Yes Shift IV Insulin + Dextrose INH Albuterol Consider NaHCO 3 Consider IV Loop Eliminate-Gut Eliminate-Dialysis Consider SPS Monitoring Whatever interventions are used to treat hyperkalemia, monitoring is essential! Recheck serum potassium level May require serial measurements Normalize electrocardiogram Reverse neuromuscuscular effects Page 6 of 6