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Hyperkalemia due to Medications

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1. Spironolactone and renin-angiotensin system drugs in heart failure: risk of potentially fatal hyperkalaemia

that increases sodium excretion while reducing potassium loss at the distal renal tubule. This mechanism of action means that hyperkalaemia can occur, particularly in patients with impaired renal function. Spironolactone should not be used in patients with severe renal impairment or pre-existing hyperkalaemia. Risk of hyperkalaemia with renin-angiotensin system drugs ACEi are mainly indicated in patients with hypertension or heart failure. ARBs are also indicated in hypertension and some are also indicated (...) spontaneous reports of abnormal blood potassium in patients using spironolactone as well as an ACEi (n=63) or ARB (n=25), 70 of which describe hyperkalaemia. 3 patients taking spironolactone and ACEi had a fatal outcome. The number of cases reported for concomitant use of spironolactone and ACEi has increased from 1999, peaking 2001–05, and has started rising again in the past 2 years (see figure). During the period from 1982 (when the first report of hyperkalaemia with this combination of medicines

2016 MHRA Drug Safety Update

2. 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 (...) hyperkalaemia (TA623) © NICE 2020. All rights reserved. Subject to Notice of rights (https://www.nice.org.uk/terms-and- conditions#notice-of-rights). Page 7 of 25people with chronic kidney disease 3b, 4 and 5 and serum potassium levels above 6.0 mmol/litre and some people with heart failure and serum potassium levels above 5.5 mmol/litre. The committee understood that many people have both heart failure and chronic kidney disease, so it may be appropriate to start drug treatment at the same serum potassium

2020 National Institute for Health and Clinical Excellence - Technology Appraisals

3. 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 (...) with adverse outcomes. New therapies have demonstrated effective control, offering hope for potential use in patients that would benefit from diet or medications associated with an increase in serum potassium, indicating that the use of hyperkalemic agents can be associated with better outcomes.

2019 Current Opinion in Nephrology and Hypertension

4. Hyperkalemia due to Medications

to Medications Hyperkalemia due to Medications Aka: Hyperkalemia due to Medications , Medication Causes of Elevated Serum Potassium , Drug-induced Hyperkalemia II. Causes: Medications causing Hyperkalemia s s (ARB) s ( , , ) s Hypertonic Infusions (Mannitol, ) s G (high dose) Transfusions of Trimethoprim (decreases urinary excretion of ) Do not combine with s, s, Higher risk with age >65 years, , and ( -like effect) III. Causes: Herbal supplements that may increase Potassium Alfalfa Amino Acids (Aminocaproic (...) acid, Arginine, Lysine) Dandelion Dried toad skin e Berry Horsetail Liliy of the Valley Milkweed Nettle Noni Juice Siberian IV. Causes: Excessive Potassium intake See Salt Substitute (e.g. Mrs. DASH) Fruits (Bananas, melons, orange juice) V. References Images: Related links to external sites (from Bing) These images are a random sampling from a Bing search on the term "Hyperkalemia due to Medications." Click on the image (or right click) to open the source website in a new browser window. Related

2018 FP Notebook

5. Sodium zirconium cyclosilicate for treating hyperkalaemia

inhibitors. The clinical experts at the second committee meeting explained they would consider drug treatment for hyperkalaemia, if a well-tolerated treatment were available, mainly to optimise the use of RAAS inhibitors. They would consider drug treatment for: people with chronic kidney disease and serum potassium levels above 6.0 mmol/litre and some people with heart failure and serum potassium levels above 5.5 mmol/litre. The committee understood that many people have both heart failure and chronic (...) into cells. Nebulised salbutamol as an adjunctive therapy to insulin and glucose for serum potassium levels of 6.5 mmol/litre and above to move potassium from the blood into cells. After severe hyperkalaemia has resolved, potassium-binding agents may be offered for 3 or more days (namely, calcium resonium given orally) to remove potassium from the body. Stopping or reducing RAAS inhibitors, which can increase serum potassium levels. Chronic hyperkalaemia is treated in outpatient care. The aim

2019 National Institute for Health and Clinical Excellence - Technology Appraisals

6. Assessment of hyperkalaemia

significant hyperkalaemia represents a true medical emergency and requires rapid implementation of measures to reduce serum potassium concentration. Differentials Chronic kidney disease Diabetic ketoacidosis/hyperosmolar hyperglycaemic state Drug-related decreased cellular entry or increased cellular exit of potassium Potassium supplementation with underlying renal dysfunction Drug-related reduced urinary potassium excretion Acute kidney failure Renal tubular acidosis Metabolic acidosis Congenital adrenal (...) potassium values can have significant muscular and cardiac effects when significant hyperkalaemia is present. Hyperkalaemia is most commonly due either to high intake of potassium in the setting of decreased renal excretion or to extracellular redistribution of potassium from intracellular locations. There is a limited correlation between an elevated serum potassium value and an excess in total body potassium stores. Clinical manifestations of hyperkalaemia are uncommon with values <6.0 mmol/L (<6.0 mEq

2018 BMJ Best Practice

7. Medical therapies to reduce chronic kidney disease progression and cardiovascular risk: anti-hypertensive/anti-proteinuric agents

before starting ACEI/ARB therapy. Repeat these measurements between 1 and 2 weeks after starting ACEI/ARB therapy and after each dose increase. R49 ACEI/ARB therapy should not normally be started if the pre-treatment serum potassium concentration is significantly above the normal reference range (typically > 5.0 mmol/l). R52 Stop ACEI/ARB therapy if the serum potassium concentration rises to above 6.0 mmol/l and other drugs known to promote hyperkalaemia have been discontinued. R54 If there is a fall (...) Medical therapies to reduce chronic kidney disease progression and cardiovascular risk: anti-hypertensive/anti-proteinuric agents ____________________________________________________________________________________________________________ Early Chronic Kidney Disease July 2012 Page 1 of 24 Medical therapies to reduce chronic kidney disease progression and cardiovascular risk: anti- hypertensive agents Date written: July 2012 Author: Richard Phoon, David Johnson GUIDELINES Non-diabetic Kidney

2013 KHA-CARI Guidelines

8. The dysfunction of ammonia in heart failure increases with an increase in the intensity of resistance exercise, even with the use of appropriate drug therapy. (Abstract)

The dysfunction of ammonia in heart failure increases with an increase in the intensity of resistance exercise, even with the use of appropriate drug therapy. Hyperammonemia during rest periods is a dysfunction in heart failure (HF). The low formation of ammonia during exercise reflects an inefficiency of purine metabolism. Hyperkalemia in response to physical exercise is common in HF and may contribute to a contractile inefficiency in type II fibers, leading to early fatigue. We tested (...) the hypothesis that during resistance exercise of high intensity and low volume, this disorder of ammonia metabolism would be more intense, due to the hyperkalemia present in HF.Alternating resistance exercise (RE) of low intensity and high volume, and high intensity and low volume, were applied to 18 patients with an interval of 7 days between them (functional class II-III New York Heart Association, FE = 33.5 ± 4%) and compared with 22 healthy controls matched for age and gender. Ammonia, potassium

2014 European journal of preventive cardiology Controlled trial quality: uncertain

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

Patiromer sorbitex calcium (Veltassa) - for the treatment of hyperkalaemia in adults 1 patiromer (as patiromer sorbitex calcium) 8.4g and 16.8g powder for oral suspension (Veltassa ® ) SMC2084 Vifor Fresenius Medical Care Renal Pharma UK Ltd 6 July 2018 The Scottish Medicines Consortium (SMC) has completed its assessment of the above product and advises NHS Boards and Area Drug and Therapeutic Committees (ADTCs) on its use in NHS Scotland. The advice is summarised as follows: ADVICE: following (...) 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

10. Patiromer (Veltassa) - hyperkalaemia

mortality risk. While rare in the healthy individuals with normal renal function, the prevalence of hyperkalaemia in patients with renal insufficiency or chronic kidney disease (CKD) ranges from 5% to 50% and increases as renal function declines. Thus, patients most at risk of hyperkalaemia are those with compromised renal excretion of potassium, primarily patients with CKD and/or patients being treated with drugs that inhibit renal potassium excretion, including renin angiotensin aldosterone system (...) inhibitors (RAASi). RAASi are used in the treatment of hypertension, CKD and congestive heart failure and compelling data and clinical practice guidelines support the use of RAASi to reduce adverse cardiovascular and renal outcomes in certain high-risk patient populations However, therapy with RAASi can be limited by hyperkalaemia resulting from treatment with these medications. In addition to CKD and the use of RAASi, diabetes and the use of beta-blockers can increase the risk of hyperkalaemia leading

2017 European Medicines Agency - EPARs

11. 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

12. Fludrocortisone therapy for persistent hyperkalaemia. (Abstract)

Fludrocortisone therapy for persistent hyperkalaemia. Type 4 renal tubular acidosis causes hyperkalaemia, for which diabetes and medications commonly used in this patient group are aetiological factors. Here we describe the novel use of fludrocortisone in this difficult condition.A 55-year-old woman with complex co-morbidities, including Type 2 diabetes (HbA1c 37 mmol/mol 5.5%), was admitted with renal failure. Bloods on admission: eGFR 25 ml/min, creatinine 184 ?mol/L, urea 35.9 mmol/L, sodium (...) days, she was commenced on fludrocortisone 50 mcg/day. Her renal function and serum potassium stabilized and she was discharged with potassium 4.3 mmol/L, eGFR 42 ml/min, and bicarbonate 23 mmol/L. She has remained stable on this treatment, without requiring further hospital admission for over 6 months, with eGFR 40 ml/min, and potassium 5.5 mmol/L, and albumin 26 g/L.This woman was presumed to have Type 4 renal tubular acidosis and recurrent hyperkalaemia due to renal insufficiency, in the context

2017 Diabetic Medicine

13. Combination use of medicines from different classes of renin-angiotensin system blocking agents: risk of hyperkalaemia, hypotension, and impaired renal function?new warnings

blocking agents: risk of hyperkalaemia, hypotension, and impaired renal function—new warnings New warnings due to risk of hyperkalaemia, hypotension, and impaired renal function have been agreed following an EU-wide review. Published 11 December 2014 From: Therapeutic area: , , Contents Article date: June 2014 The renin-angiotensin hormone system (RAS) controls blood pressure and the volume of fluids in the body. Medicines that have an inhibitory action on the RAS (RAS blocking agents) are used (...) failure may have a medical need for treatment with an ACE-inhibitor and an ARB. Candesartan and valsartan are licensed as add-on therapy to ACE-inhibitors for people with symptomatic heart failure who require such a combination despite optimal therapy. The triple combination of an ACE-inhibitor, ARB, and a mineralocorticoid receptor antagonist or other potassium-sparing diuretic is not recommended. Patients currently taking a combination of RAS blocking agents Review the treatment of all patients

2014 MHRA Drug Safety Update

14. New drugs for hyperkalemia

New drugs for hyperkalemia db's Medical Rants » Blog Archive » New drugs for hyperkalemia Internal medicine, American health care, and especially medical education 1 Posted by rcentor | Posted on 21-05-2018 Category : The US Food and Drug Administration (FDA) has approved sodium zirconium cyclosilicate (Lokelma, AstraZeneca) — a medication that rapidly restores normal potassium levels — for adults with hyperkalemia. Formerly known as ZS-9, the drug is a “highly-selective, oral potassium (...) . And these patients have an absolute indication for an ACE-I or ARB. Thus, we have a conundrum. How do we successfully treat their systolic dysfunction or progressive CKD. Drug companies see an niche. Sodium polysterene (Kayexalate) is not adequate due to dangerous side effects. Patiromer (Valtessa) was released first, now this new option. What will be their roles? What will be the pricing? This is all interesting, and we will follow the indications for its use with interest. Share this: Like this: Like Loading

2018 db's Medical Rants blog

15. Developing strategies for predicting hyperkalemia in potassium-increasing drug-drug interactions. Full Text available with Trip Pro

Developing strategies for predicting hyperkalemia in potassium-increasing drug-drug interactions. To compare different strategies predicting hyperkalemia (serum potassium level ≥5.5 mEq/l) in hospitalized patients for whom medications triggering potassium-increasing drug-drug interactions (DDIs) were ordered.We investigated 5 strategies that combined prediction triggered at onset of DDI versus continuous monitoring and taking into account an increasing number of patient parameters (...) at the onset of DDI ranged from 1.79% (undifferentiated anticipation of hyperkalemia due to the DDI) to 3.02% (additionally considering the baseline serum potassium) and 3.10% (including further patient parameters). Continuous monitoring significantly increased the PPV to 8.25% (considering the current serum potassium) and 9.34% (additional patient parameters).Continuous monitoring of the risk for hyperkalemia based on current potassium level shows a better predictive power than predictions triggered

2016 Journal of the American Medical Informatics Association

16. Recommendations for Management of Clinically Significant Drug-Drug Interactions With Statins and Select Agents Used in Patients With Cardiovascular Disease: A Scientific Statement From the American Heart Association

: Introduction A drug-drug interaction (DDI) is a pharmacokinetic or pharmacological influence of 1 medication on another that differs from the known or anticipated effects of each agent alone. A DDI may result in a change in either drug efficacy or drug toxicity for 1 or both of the interacting medications. Pharmacokinetic DDIs result in altered absorption, distribution, metabolism, or excretion of a medication. A pharmacodynamic DDI occurs when 1 medication modifies the pharmacological effect of another (...) in an additive, a synergistic, or an antagonistic fashion. It is estimated that ≈2.8% of hospital admissions occur as a direct result of DDIs. However, the actual incidence of hospitalization secondary to clinically significant DDIs is likely to be highly underestimated because medication-related issues are more commonly reported as adverse drug reactions. Complex underlying disease states also may make recognizing a DDI more challenging, further contributing to a lower reported incidence. The overall

2016 American Heart Association

17. CRACKCast E152 – Cardiovascular Drugs

CRACKCast E152 – Cardiovascular Drugs CRACKCast E152 - Cardiovascular Drugs - CanadiEM CRACKCast E152 – Cardiovascular Drugs In by Chris Lipp February 26, 2018 This episode of CRACKCast covers Rosen’s 9th Ed Chapter 147, Cardiovascular Drugs. With increasingly common use of these medications for heart disease and an ever aging population, it is imperative to understand the prompt recognition and therapy for toxic exposures. Recognition of the more lethal agents and how to disposition (...) Labs: serum potassium level above 5.0 mEq/L (acute ingestion) Acute steady state > 13 nmol/L and one clinical sign Any serum level > 19 nmol/L (this is not a steady state level, will change after drug distributes) Fab fragment therapy should be used before transvenous pacing, because the latter is believed to carry risk of ventricular dysrhythmia, although the evidence for this is mixed. The peak level at 2 hrs is usually MUCH higher than the actual steady state level (suggest false toxicity

2018 CandiEM

18. Renin-angiotensin system drugs

heart failure and there was an increased risk of hyperkalaemia, hypotension, and impaired renal function. See the NICE medicines evidence commentary Efficacy and safety of dual blockade of the renin-angiotensin system for more information. UK Medicines Information (UKMi) has also published a medicines question and answers resource on the rationale and evidence for combining ACE inhibitors with ARBs for treating hypertension and for preventing vascular events. Dual therapy has only a limited place (...) of rights (https://www.nice.org.uk/terms-and- conditions#notice-of-rights). Page 1 of 6ACE inhibitors in this situation. The MHRA states that the triple combination of an ACE inhibitor, an ARB, and a mineralocorticoid receptor antagonist or other potassium-sparing diuretic in people with heart failure is not recommended. UKMi has published a medicines question and answers resource on the use of a combination of ACE inhibitors with ARBs in patients with heart failure. In the June 2014 edition of Drug

2015 National Institute for Health and Clinical Excellence - Advice

19. Sodium Zirconium cyclosilicate for hyperkalaemia - first line

. At levels above 6.5mmol/L, the risk of ventricular fibrillation or asystole increases quickly. The majority of cases of hyperkalaemia are observed in those patients prescribed angiotensin converting enzyme (ACE) inhibitors or angiotensin II receptor blockers (ARBs), often in conjunction with spironolactone in those with pre-existing or new renal impairment. Hyperkalaemia occurs in up to 10% of hospitalised patients, of which 77% of cases are thought to be due to renal failure and 63% to prescribed drugs (...) . In 2012-13, there were 6,344 admissions for hyperkalaemia in England, resulting in 20,457 bed-days and 8,662 finished consultant episodes. The treatment of hyperkalaemia involves the removal of any precipitating drugs and reduction of excess potassium from fluids or food. Calcium gluconate is given to reduce cardiac cell membrane excitability. To help shift potassium from the extracellular domain to the intracellular space, patients may be given a rapid acting insulin (with glucose to avoid

2015 Health Technology Assessment (HTA) Database.

20. Patiromer for hyperkalaemia - first line

is intended for the treatment of acute and/or chronic hyperkalaemia in patients with chronic kidney disease, type 2 diabetes or chronic heart failure. If licensed, patiromer will offer a novel treatment option for hyperkalaemia in this patient group who currently have few well-tolerated effective therapies available. Patiromer is a non-absorbed cation-exchange polymer that binds potassium predominantly in the lumen of the colon where potassium is the most abundant cation. Patiromer does not currently have (...) Marketing Authorisation in the EU for any indication. The incidence of hyperkalaemia varies between 1.1% and 10% of hospital patients, of which 77% of cases are thought to be due to renal failure, 63% to prescribed drugs, and 49% to hyperglycaemia. Hyperkalaemia is the reason for emergency haemodialysis in 24% of haemodialysis patients and accounts for 3-5% of deaths in this patient group. In 2013-14, there were 7,214 hospital admissions for hyperkalaemia in England, resulting in 20,725 bed days

2015 Health Technology Assessment (HTA) Database.

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