Emergency management of severe hyperkalemia still is largely based on traditional practice with little supporting evidence, according to an international group of researchers.

“Unfortunately, standard treatments are neither without risks [n]or supported by a compelling body of evidence, and they are applied inconsistently,” Patrick Rossignol, MD, PhD, of the Université de Lorraine in France, and colleagues remarked in a paper published recently in Pharmacological Research.

The paper presented a summary of a 2015 meeting of the Investigator Network Initiative Cardiovascular and Renal Trialists, which convened to address knowledge gaps in the management of emergency severe hyperkalemia. The panel recommended that future trials evaluate standard interventions for efficacy in lowering potassium levels and improving electrocardiogram (EKG) readings.

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A specific serum potassium threshold and kinetic pattern leading to cardiac arrhythmias still need to be identified, according to the investigators. Likewise, uncertainties exist around which EKG abnormalities predict outcome, whether peaked T-waves, conduction system abnormalities, sine wave, or widening QRS. The optimal rate for correcting potassium is also unknown.

According to the group, newer potassium binders, specifically patiromer and ZS-9, might play a role in treating severe hyperkalemia; for example, if their onset follows acute treatment, the drugs might help prevent recurrence. “Whether new potassium binders will play a role in the emergency management of severe hyperkalemia remains to be seen, but it is worth investigating their ability to lower potassium in a timely manner to reduce the need for insulin with glucose, β2 agonists, and dialysis,” Dr Rossignol and colleagues stated.

The meeting was funded by a grant from ZS Pharma, the makers of ZS-9. Authors of the paper disclosed fees and relationships with various pharmaceutical companies.

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1. Rossignol P,  Matthieu L, Mikhail K, et al. Emergency management of severe hyperkalemia: Guideline for best practice and opportunities for the future. Pharm Res. doi: 10.1016/j.phrs.2016.09.039.