Is This High Potassium for Real and How Do I Treat It?
By Sean Heffelfinger, MD, CMD
One of the more common clinical scenarios that I get presented with in long-term care is a BMP with elevated potassium. Sometimes the elevated potassium makes sense because I will notice a decline in the GFR from previous labs or I will have recently started the patient on an ACE inhibitor or received a report that fluid intake has recently decreased.
My first step is trying to determine if this is a spurious finding of hyperkalemia or not. Potassium levels can be falsely elevated by hemolysis in vitro which can be caused by prolonged fist clenching during the blood draw, use of too narrow of a gauge of needle, prolonged use of the tourniquet, delay in processing the blood sample or longer than necessary centrifugation time. Fortunately, the report will usually tell me if the sample appeared hemolyzed in the lab based on the color of the blood sample. Markedly elevated levels of platelets and leukocytes can also cause the serum levels of potassium to be elevated due to the release of potassium from these cells.
After you determine if your patient’s elevated potassium needs treatment, the next step is determining what medication to use to treat it. I would just like to concentrate in this short review article on oral medications to treat hyperkalemia that doesn’t warrant emergent treatment in a hospital setting.
Sodium polystyrene sulfonate (more commonly remembered as Kayexalate) had been my go-to med during residency and for my 20 plus years as an attending. It can be given orally or rectally and was cheap (about $10 a dose) and readily available. It has a quick onset of action (2-6 hours) but a short duration of action (4-6 hours). It offers a reduction of potassium from 0.8 to 1.4 mEq/L based on dose and duration. It does have significant drug interactions and needs to be administered three hours before and after other medications. This medication is known to lead to hospitalizations due to serious gastrointestinal events such as intestinal ischemia and necrosis. Because of this my old faithful standby is no longer felt to be the first-line oral medication to treat hyperkalemia.
One of the two newer agents to treat hyperkalemia is sodium zirconium cyclosilicate (Lokelma). I noticed that my local hospital system had been using this for the last few years to treat hyperkalemia in the ER if more acute treatment wasn’t indicated. The standard treatment regimen is 10 g orally three times a day for two days. It causes a modest decrease of 0.67 mEq/L at 48 hours. It doesn’t have any dangerous GI side effects, but its administration does need to be separated from other medications by two hours. This has now become my go-to medication to treat hyperkalemia in my nursing home residents. I usually check a potassium level the next day and if it is in range I will not give the remaining doses of the regimen since the medication has a duration of effect up to 12 hours. The only thing that I feel guilty about when using it is the price tag – one dose costs about $25.
The other new oral medication that has less utility for us in the long-term care setting is patiromer (Veltassa). This medication is given once a day. It has a longer onset of action (7 hours) than the others and needs four weeks to lower serum potassium by 0.70 mEq/L. I would not use this to acutely treat an elevated potassium level on a lab. I notice this medication in recent years being given on a daily basis to some of my heart failure patients with CKD so they can safely continue their renin-angiotensin-aldosterone system blockade medication regimen. The price for this starts at $1000 a month.
Any views or opinions presented in this article are solely those of the author and do not necessarily represent any policy or position of PAMED, PMDA, AMDA, its affiliates, and members.
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Nominees Sought for the 2023 Long-Term Care Clinician of the Year Award, September 11, 2023 Deadline
Periodically, the Pennsylvania Society for Post-Acute and Long-Term Care Medicine recognizes the dedication, performance, and outstanding accomplishments of a PMDA member with the presentation of the Long-Term Care Clinician of the Year Award.
The Long-Term Care Clinician of the Year Award is conferred on the clinician who demonstrates excellence in providing and/or promoting quality clinical care in the long-term care arena. Those recognized possess the vision, passion, leadership, knowledge, and commitment that takes patient care to exceptional levels of quality, excellence, and innovation in the facilities in which they serve.
Nominees for the Long-Term Care Clinician of the Year Award are PMDA members nominated by NHA, DN, medical director, or other clinicians from a SNF, ALF, or LIFE Program facility where the nominee serves as a physician, NP, or PA.
Nominating a candidate is EASY. Follow this link, complete the short form, and upload the candidate’s CV and any additional supporting material you think relevant to the nomination. The deadline is September 11, 2023.
Please consider nominating a deserving individual from your facility for the PMDA 2023 Clinician of the Year Award.
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The PMDA Board of Directors is Looking for A New Board Member
The Pennsylvania Society for Post-Acute and Long-Term Care Medicine is accepting nominations for its Board of Directors. The deadline is September 15, 2023.
This is your opportunity to be a champion for quality medical care across the post-acute and long-term care continuum and to help PMDA provide advocacy, education, and professional development opportunities for all members of the interdisciplinary health care team.
We are seeking a new member to serve on our Board of Directors. Board members are elected to three-year terms and may serve a maximum of two, consecutive three-year terms. The Board typically meets two times a year: once in conjunction with the annual scientific symposium and once in conjunction with the spring symposium. Additional meetings are convened as needed.
To be eligible, you must be a PMDA member in good standing. Please keep the following recommendations in mind when submitting a nomination:
- Directors serve on the board for a minimum three-year term
- Nominations for board election should highlight the candidate's proven understanding of PALTC medicine and commitment to the mission of PMDA
- Board members are expected to abide by our conflict of interest and whistleblower policy
Self-nominations are strongly encouraged. PMDA values and seeks diverse leadership and leaders from all types and sizes of eligible organizations.
Thank you for your consideration and support of PMDA. If you have questions, please reach out to us at pmda@pamedsoc.org
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Reunite with colleagues from across the state and network with others at the Pennsylvania Society for Post-Acute and Long-Term Care Medicine’s 31st Annual Symposium this October! This is a one-and-a-half-day educational event for all members of interprofessional teams of health care professionals who provide care to older adults residing in the full spectrum of long-term care facilities.
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Still NOT a PMDA Member?
You can become a member of PMDA by clicking on the membership application below.
To pay for your membership dues, you may either mail a check to PMDA (400 Winding Creek Blvd., Mechanicsburg, PA 17050) or complete the credit card/billing information in the membership application or call Jill Bennish, Finance Coordinator at 717-909-2679 to pay via credit card over the phone. And If you have any questions about membership, please contact PMDA at pmda@pamedsoc.org.
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If you have any questions about membership, please contact PMDA at pmda@pamedsoc.org.
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PALTC23 Conference Recordings Now Available
Did you miss AMDA’s annual conference this past March? Don’t worry—you can still earn credits for the general and concurrent sessions by purchasing the recordings. CME, CMD, and MOC credits are available.
Recorded sessions include:
- Audio synced to slides for most 60 and 90-minute sessions delivered during the conference
- Ability to download session handouts
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Safety Program for MRSA Prevention
AHRQ is seeking nursing homes and skilled nursing facilities to join a national program aimed at reducing skin and soft tissue infections, including those caused by MRSA and other Multidrug-Resistant Organisms (MRDO). The free, 18-month program will begin in June 2023.
Participation will provide your LTC facilities with technical assistance, coaching, webinars, and tools to support their infection prevention program.
Up to 19 continuing education credits will be offered at no charge for participants.
Register for an informational webinar to learn more:
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This program is funded and guided by the Agency for Healthcare Research and Quality and led by the Johns Hopkins Armstrong Institute for Patient Safety and Quality and NORC at the University of Chicago. |
Start Your Journey to Certification
The road to becoming a Certified Medical Director starts with the Core Curriculum. You can finish this year if you start now!
- The Online Core Curriculum is the first part of the Core Curriculum, covering 22 critical areas impacting PALTC leadership and management.
- The Core Synthesis is comprised of dynamic lectures, spirited role plays, case-based discussion, and small group breakouts.
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AMDA On-The-Go
Podcast Series
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