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Hyperkalemia Management

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1. Patiromer for treating hyperkalaemia

RAAS inhibitors at serum potassium levels of more than 6.0 mmol/litre. The committee acknowledged that this was in line with NICE's clinical guideline on chronic kidney disease in adults: assessment and management. The clinical experts at the second committee meeting explained they would consider drug treatment for hyperkalaemia, if there is a well- tolerated treatment available, mainly to optimise the use of RAAS inhibitors. They would consider drug treatment for: Patiromer for treating (...) of NICE's guidance which recommends stopping RAAS inhibitors at serum potassium levels of 6.0 mmol/litre and above Patiromer for treating hyperkalaemia (TA623) © NICE 2020. All rights reserved. Subject to Notice of rights (https://www.nice.org.uk/terms-and- conditions#notice-of-rights). Page 15 of 25(see section 3.3). It concluded that starting RAAS inhibitors prolongs life for many people, so stopping them for people who benefit from them would likely shorten life. There is insufficient evidence

2020 National Institute for Health and Clinical Excellence - Technology Appraisals

2. Evidence in support of hyperkalaemia management strategies: A systematic literature review (Abstract)

Evidence in support of hyperkalaemia management strategies: A systematic literature review Hyperkalaemia is a potentially life-threatening condition that can be managed with pharmacological and non-pharmacological approaches. With the recent development of new hyperkalaemia treatments, new information on safe and effective management of hyperkalaemia has emerged.This systematic literature review (SLR) aimed to identify all relevant comparative and non-comparative clinical data on management (...) of hyperkalaemia in adults. Our secondary aim was to assess the feasibility of quantitatively comparing randomised controlled trial (RCT) data on the novel treatment sodium zirconium cyclosilicate (ZS) and established pharmacological treatments for the non-emergency management of hyperkalaemia, such as the cation-exchangers sodium/calcium polystyrene sulphonate (SPS/CPS).MEDLINE, Embase and the Cochrane Library were searched on 3rd April 2017, with additional hand-searches of key congresses and previous SLRs

2018 EvidenceUpdates

3. Sodium zirconium cyclosilicate for treating hyperkalaemia

before this guidance was published. People having treatment outside this recommendation may continue without change to the funding arrangements in place for them before this guidance was published, until they and their NHS clinician consider it appropriate to stop. Wh Why the committee made these recommendations y the committee made these recommendations Sodium zirconium cyclosilicate is a treatment for people with high blood potassium levels (hyperkalaemia). It may benefit adults with chronic kidney (...) and trimethoprim. The clinical expert at the first committee meeting explained that people who have normal serum potassium levels after emergency treatment do not have long-term (maintenance) treatment with a potassium-lowering drug in current clinical practice. He also noted that calcium resonium is poorly tolerated by patients. The committee concluded that managing acute life-threatening hyperkalaemia differs from managing persistent but non-life-threatening hyperkalaemia, which justified the separate

2019 National Institute for Health and Clinical Excellence - Technology Appraisals

4. New frontiers for management of hyperkalaemia: the emergence of novel agents. Full Text available with Trip Pro

New frontiers for management of hyperkalaemia: the emergence of novel agents. Hyperkalaemia is a common electrolyte abnormality, associated with higher risk of morbid events, and increasing in prevalence-in part, due to increasing rates of comorbidities such as heart failure, chronic kidney disease, diabetes mellitus, and the use of renin-angiotensin-aldosterone system inhibitors (RAASi). In spite of this growing problem, the existing treatments for chronic hyperkalaemia have been limited (...) , and are typically confined to dietary potassium restrictions and cessation or modification of RAASi, with latter option being potentially problematic given the known morbidity and mortality benefit of RAASi therapy in certain disease states, such as heart failure. The use of sodium polystyrene sulfonate (SPS/Kayexelate) for chronic hyperkalaemia has been low, due to poor tolerability, potential gastrointestinal safety concerns, and remaining uncertainty in regards to its efficacy. Given the shortcomings

2019 European Heart Journal Supplements

5. A new area for the management of hyperkalaemia with potassium binders: clinical use in nephrology. Full Text available with Trip Pro

A new area for the management of hyperkalaemia with potassium binders: clinical use in nephrology. Chronic kidney disease (CKD) patients and more so CKD patients treated with renin-angiotensin-aldosterone system inhibitors (RAASi) are prone to experience hyperkalaemia, a condition associated with an increased risk of death. This represents a true dilemma in daily practice since RAASi are the cornerstones of nephroprotective and cardioprotective strategies in CKD patients, as well (...) as in hypertensive patients with or without CKD. The recent availability in the USA and EU of the potassium-binding resin Patiromer, together with sodium zirconium cyclosilicate (SZC), which was more recently approved in the EU and the US, may lead to a paradigm shift both in the treatment of hyperkalaemia and in enabling RAASi maintenance. Whether potassium normalization, potentially combined with a RAASi maintenance strategy, may translate into improved cardiovascular and renal outcomes needs be tested

2019 European Heart Journal Supplements

6. Sodium zirconium cyclosilicate (Lokelma) - treatment of hyperkalaemia in adult patients

, moderate as 6.0 to 6.4 mmol/L and severe as =6.5 mmol/L. The level of raised serum potassium at which treatment is initiated can be influenced by clinical considerations, including co-morbidities. 2 The 2014 UK Renal Association clinical practice guideline on the treatment of acute hyperkalaemia in adults provided guidance on the treatment of moderate to severe hyperkalaemia (as defined above). It recommends a logical step-wise approach. The first step is to protect the heart and it recommends (...) with RAASi. 14 In January 2015 the National Institute for Health and Care Excellence (NICE) published an updated version of Clinical Guideline 182: Chronic kidney disease in adults: assessment and management. This guidance makes the following relevant recommendations: ? Do not routinely offer a RAAS inhibitor to people with CKD if their pretreatment serum potassium concentration is greater than 5.0mmol/L. ? When hyperkalaemia precludes use of renin–angiotensin system antagonists, assessment

2020 Scottish Medicines Consortium

7. Management of Hyperkalemia With Insulin and Glucose: Pearls for the Emergency Clinician. (Abstract)

Management of Hyperkalemia With Insulin and Glucose: Pearls for the Emergency Clinician. Hyperkalemia is a common, potentially lethal clinical condition that accounts for a significant number of emergency department (ED) visits. Insulin and dextrose are frequently used to manage patients with hyperkalemia.This narrative review evaluates several myths concerning hyperkalemia treatment with insulin and dextrose in the ED and provides recommendations based on the current evidence.Hyperkalemia (...) is a life-threatening condition requiring emergent therapy. One of these therapies includes insulin with glucose. However, hypoglycemia after insulin use is a frequent complication during hyperkalemia management. The published literature suggests that low pretreatment glucose, no history of diabetes mellitus, female gender, abnormal renal function, and lower body weight increase the risk of hypoglycemia. Several strategies can reduce the risk of hypoglycemia with insulin therapy, which include using

2019 Journal of Emergency Medicine

8. Updates on medical management of hyperkalemia. (Abstract)

Updates on medical management of hyperkalemia. Hyperkalemia is a potentially fatal electrolyte disorder, more commonly present when the potassium excretion capacity is imparied. Hyperkalemia can lead to adverse outcomes, especially due to severe cardiac arrhythmias. It can also impair the cardiovascular effects of renin-angiotensin-aldosterone system inhibitors (RAASis) and potassium rich diets, as hyperkalemia frequently leads to their discontinuation.Potassium is a predictor of mortality (...) and should be monitored closely for patients who are at risk for hyperkalemia. Acute hyperkalemia protocols have been revised and updated. Randomized trials have shown that the new anti-hyperkalemic agents (patiromer and zirconium cyclosilicate) are effective hyperkalemia treatment options. The use of anti-hyperkalemic agents may allow for a less restrictive potassium diet and lower RAASi discontinuation rates.Hyperkalemia should be monitored closely for high-risk patients, as it is associated

2019 Current Opinion in Nephrology and Hypertension

9. Incidence, predictors and clinical management of hyperkalaemia in new users of mineralocorticoid receptor antagonists. Full Text available with Trip Pro

Incidence, predictors and clinical management of hyperkalaemia in new users of mineralocorticoid receptor antagonists. Concerns for hyperkalaemia limit the use of mineralocorticoid receptor antagonists (MRAs). The frequency of MRA-associated hyperkalaemia in real-world settings and the extent of subsequent MRA discontinuation are poorly quantified.Observational study including all Stockholm citizens initiating MRA therapy during 2007-2010. Hyperkalaemias were identified from all potassium (K (...) + ) measurements in healthcare. MRA treatment lengths and dosages were obtained from complete collection of pharmacy dispensations. We assessed the 1-year incidence and clinical hyperkalaemia predictors, and quantified drug prescription changes after an episode of hyperkalaemia. Overall, 13 726 new users of MRA were included, with median age of 73 years, 53% women and median plasma K+ of 3.9 mmol/L. Within a year, 18.5% experienced at least one detected hyperkalaemia (K+  > 5.0 mmol/L), the majority within

2018 European Journal of Heart Failure

10. Patiromer (Veltassa) - for the treatment of hyperkalaemia in adults

In April 2018, Vifor submitted a dossier to examine the cost-effectiveness of patiromer (Veltassa®) under the community drug schemes. Patiromer is licensed for the treatment of hyperkalaemia in adults. There is no universal consensus definition of what serum potassium level constitutes hyperkalaemia. Various arbitrary cut-offs such as >5, >5.5 or >6 mmol/L are used to denote different levels of severity. Patiromer (Veltassa®) is a non-absorbed, cation exchange polymer that contains a calcium sorbitol (...) (RAAS) inhibitors who experience hyperkalaemia defined as a serum potassium (K+) level from 5.5 to 5.5mmol/L or higher at baseline of the initial treatment phase ? A potassium level at the end of the initial treatment phase that was within the target range while receiving patiromer and RAAS inhibitors Consenting eligible patients were randomised in a 1:1 ratio to continue receiving patiromer (at the same daily dose they were receiving at week four of the initial treatment phase) or to receive

2019 Pediatric Endocrine Society

11. Controversies in Management of Hyperkalemia. (Abstract)

Controversies in Management of Hyperkalemia. Hyperkalemia is a common electrolyte disorder that can result in morbidity and mortality if not managed appropriately.This review evaluates the classic treatments of hyperkalemia and discusses controversies and new medications for management.Potassium (K+) plays a key role in determining the transmembrane potentials of "excitable membranes" present in nerve and muscle cells. K+ is the predominant intracellular cation, and clinical deterioration (...) typically ensues when patients develop sufficiently marked elevation in extracellular fluid concentrations of K+ (hyperkalemia). Hyperkalemia is usually detected via serum clinical laboratory measurement. The most severe effect of hyperkalemia includes various cardiac dysrhythmias, which may result in cardiac arrest and death. Treatment includes measures to "stabilize" cardiac membranes, to shift K+ from extracellular to intracellular stores, and to promote K+ excretion. Calcium gluconate 10% dosed 10

2018 Journal of Emergency Medicine

12. Potassium Additives and Bioavailability: Are We Missing Something in Hyperkalemia Management? (Abstract)

Potassium Additives and Bioavailability: Are We Missing Something in Hyperkalemia Management? Hyperkalemia and hyperphosphatemia are common metabolic disturbances in chronic kidney disease. Management may include instructions on a low-potassium or low-phosphorus diet, respectively. Low-phosphorus diet teaching includes information on phosphorus additives in addition to naturally occurring phosphorus food sources. Phosphorus additives are known to be more bioavailable compared with naturally (...) occurring phosphorus. The concentration of phosphorus can also be much higher in processed foods compared with whole foods. Similar considerations may also be needed for dietary potassium teaching. The use of potassium additives in processed foods is growing, and when additives are used, the potassium concentration far exceeds naturally occurring potassium. Evidence also suggests, much like phosphate, potassium additives are more bioavailable than potassium found in whole foods. Clinicians and patients

2018 Journal of Renal Nutrition

13. Patiromer sorbitex calcium (Veltassa) - for the treatment of hyperkalaemia in adults

disease [ESRD]), hyperkalaemia (serum potassium =5.5mmol/L) resulting in hospitalisation, CV event (myocardial infarction [MI] or stroke) followed by post CV event, or straight to the CV event state, and death (from each state). In the model long term CKD and CV benefits from patiromer were primarily driven by the impact of facilitating RAAS inhibitor continuation from the management of hyperkalaemia. The primary clinical data used in the economic analysis was post hoc analysis of the proportion (...) with acute hyperkalaemia normally manage their condition with multiple treatments. Kidney patients are already taking multiple medications due to comorbidities and are often on dialysis due to end stage kidney failure. This adds to the overall burden of multiple side effects and emotional/mental pressure, especially for older and vulnerable patients. For chronic or 10 recurrent hyperkalaemia, most treatment options are limited to low potassium diet, diuretics and modification of hyperkalaemia-inducing

2018 Scottish Medicines Consortium

14. Patiromer (Veltassa) - hyperkalaemia

to management has relied on dietary potassium restriction, RAASi dose reduction or discontinuation, diuretics, oral bicarbonate and if applicable, the use of the cation exchange resins sodium polystyrene sulfonate or calcium polystyrene sulfonate. The use of dietary potassium restriction to manage hyperkalaemia is difficult due to the ubiquitous presence of potassium in foods. Sodium polystyrene sulfonate and calcium polystyrene sulfonate are two cation-exchange resins currently approved in the EU (...) ) Enrolled and Treated: 12 (12/0) Healthy subjects 18 days Complete; CSR PD RLY5016-1 03 Evaluate the time to onset of potassium-lowering action of RLY5016 Powder for Oral Suspension Open-label, single arm, multiple dose Fixed Dose: 16.8 g/day c (as divided dose BID) Enrolled and Treated: 25 (25/0) Hyperkalemia and CKD 2 days Complete; CSR PD RLY5016-2 01 Assess the PD effects of RLY5016 Powder for Oral Suspension on serum potassium in hyperkalemic subjects Open-label, single arm, multiple-dose Fixed

2017 European Medicines Agency - EPARs

15. Primary care: Trimethoprim is associated with a greater risk of acute kidney injury and hyperkalaemia in older adults compared with other antibiotics used to treat UTIs

Primary care: Trimethoprim is associated with a greater risk of acute kidney injury and hyperkalaemia in older adults compared with other antibiotics used to treat UTIs Trimethoprim is associated with a greater risk of acute kidney injury and hyperkalaemia in older adults compared with other antibiotics used to treat UTIs | BMJ Evidence-Based Medicine We use cookies to improve our service and to tailor our content and advertising to you. You can manage your cookie settings via your browser (...) 2018;360:k341. Context Urinary tract infection (UTI) is the most common bacterial infection in older adults. Trimethoprim is a first-line antibiotic prescribed in the UK for acuteuncomplicated UTI. Trimethoprim reduces potassium excretion in the distal nephron, which can cause elevated potassium levels. This is of particular importance in older adults, who are more likely to have comorbidities requiring prescription of additional medicines that may predispose them to hyperkalaemia, such as renin

2018 Evidence-Based Medicine

16. Sodium zirconium cyclosilicate (Lokelma) - Hyperkalemia

of hospitalised patients, and the incidence ranges from 1 to 10%. There is no agreed definition of hyperkalaemia, since the raised level of potassium at which a treatment should be initiated has not been established. The European Resuscitation Council guidelines consider hyperkalaemia to be a serum potassium (S-K) level > 5.5 mmol/L, with mild elevations defined as 5.5 to 5.9 mmol/L, moderate as 6.0-6.4 mmol/L, and severe as = 6.5 mmol/L. The guidelines also note that extracellular potassium levels (...) with S-K levels between 3.5 and 4.5 mmol/L but, more importantly, S-K levels between 4.5 and 5.0 mmol/L, which is within the normal range, were associated with a 2-fold increased risk of mortality compared with S-K between 3.5 and 4.5 mmol/L. 2.1.2. Epidemiology Hyperkalemia develops when there is insufficient elimination, excessive intake, or shift of potassium from the intracellular space. Insufficient elimination, which is the most common cause of hyperkalaemia, can be hormonal (as in aldosterone

2018 European Medicines Agency - EPARs

17. How reliable are ECG findings in hyperkalemia?

prolongation, 24 had T-wave findings, and the majority were nonspecific. Additionally, the interobserver reliability was moderate. In a separate study of 170 patients with normal potassium levels and 135 patients with potassium >6 mmol/l, 24% of normokalemic patients and 46% of patients with elevated potassium levels had ECG findings suggestive of hyperkalemia. These studies suggest ECG findings should be used with careful consideration in the management of hyperkalemia. References: Patients with type 2 (...) How reliable are ECG findings in hyperkalemia? Chiefs’ Inquiry Corner – 10/14/19 – Clinical Correlations Search Chiefs’ Inquiry Corner – 10/14/19 October 14, 2019 2 min read The concentration and dose of epinephrine varies by indication. In 2016, the FDA banned the use of ratio expressions of epinephrine dosing, so clinicians should learn concentration-based dosing. An epinephrine auto-injector (aka EpiPen) contains the highest concentration of epinephrine at 1mg/mL. A dose of 0.3mg (0.3mL

2019 Clinical Correlations

18. Managing hyperkalemia in high-risk patients in long-term care. (Abstract)

Managing hyperkalemia in high-risk patients in long-term care. Hyperkalemia is common among elderly patients and is associated with an increase in morbidity and mortality. Patients at highest risk for developing hyperkalemia are those with chronic kidney disease (CKD) and heart failure (HF), particularly those on guideline-recommended inhibitors of the renin-angiotensin-aldosterone system (RAAS). Hyperkalemia remains a challenge for clinicians practicing in the long-term care setting (...) as they are often faced with the difficult decision of down-titrating or discontinuing RAAS inhibitors in response to hyperkalemia in the very patients who derive the greatest benefit from these agents. In the past, options to chronically manage hyperkalemia were limited. Patiromer was approved for the treatment of hyperkalemia in 2015 and has been shown to maintain normokalemia for up to 52 weeks in patients with CKD and/or HF on RAAS inhibitors. With the emergence of a new hyperkalemia treatment, there could

2017 American Journal Of Managed Care

19. Challenges in Treating Cardiovascular Disease: Restricting Sodium and Managing Hyperkalemia. Full Text available with Trip Pro

Challenges in Treating Cardiovascular Disease: Restricting Sodium and Managing Hyperkalemia. High sodium intake, whether via diet or drugs, augments cardiorenal risk. Regardless of its source, high sodium intake can both lead to hypertension and reduce the efficacy of renin-angiotensin-aldosterone system inhibitors, which are currently guideline-recommended treatments for hypertension, chronic kidney disease, and heart failure. Reducing sodium intake is therefore recommended to reduce the risk (...) of adverse cardiorenal outcomes. An inverse relationship exists between sodium and potassium, with foods high in sodium being lower in potassium. Diets high in potassium have been associated with reducing hypertension and heart failure; however, optimal renin-angiotensin-aldosterone system inhibitor dosing is often limited by hyperkalemia, which can lead to life-threatening cardiac arrhythmias and increased mortality. Potassium binders are effective at reducing potassium levels. Although some use sodium

2017 Mayo Clinic Proceedings

20. Advances in the management of hyperkalemia in chronic kidney disease. (Abstract)

Advances in the management of hyperkalemia in chronic kidney disease. Patients with chronic kidney disease (CKD) have an increased risk of hyperkalemia that increases both short-term and long-term mortality. Historically, managing hyperkalemia has relied upon dietary modifications, augmentation of urinary potassium excretion and enhanced enteral potassium elimination. This review discusses current treatments and their limitations and summarizes the evidence supporting novel agents for potassium (...) lowering in patients with CKD.The introduction of two novel ion exchange resins represents the first new pharmacologic therapies for hyperkalemia in the last 50 years. Patiromer, which was recently approved for use in the United States, has been shown to be well tolerated and effective for decreasing serum potassium in patients with CKD when taken for up to a year. Sodium zirconium cyclosilicate for which approval is pending has also shown promise in treating both acute and chronic hyperkalemia

2017 Current Opinion in Nephrology and Hypertension

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