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Managing Hyperkalemia with Insulin/Glucose

June 27, 2019

Written by Alex Chen, MD

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Use of insulin/glucose to treat hyperkalemia works, but hypoglycemia is a common side effect. Here are some pearls to give this treatment more safely.

Why does this matter?
Hyperkalemia is a life-threatening condition that requires prompt management in the ED. One of the most common treatment options is the administration of insulin and glucose to help shift potassium into the cell temporarily. Usually this is ordered as 10 units of regular insulin IV and 1 ampule of D50. This article explores some common myths and debunks them.

“Pour some sugar on me!”

  1. Consider decreasing insulin dose (5 units or 0.1 U/kg) or increasing dextrose load (50 g) in patients with one or more of the following risk factors:

    • Pretreatment blood glucose (BG) < 150 mg/dL

    • Acute kidney injury/chronic kidney disease

    • No history of diabetes mellitus

    • Weight < 60 kg

    • Female sex.

  2. An insulin dose of 5 units (or 0.1 U/kg) has similar efficacy as 10 units and may be safer. The exception to this was seen in a subset of patients with initial potassium levels > 6 mmol/L, where the 10 U group was superior to the 5 U group (K decreased by 1.08 mmol/L vs 0.83 mmol/L, respectively, p=0.018).

  3. A dose of 25 g of dextrose (1 amp of D50) may be inadequate for hypoglycemia prevention, especially in patients with kidney disease and decreased clearance of insulin. Consider a higher dose of dextrose (2 amps, 50 g) or giving it with the insulin as a 4h infusion to decrease the incidence of hypoglycemia.

  4. You should monitor blood glucose levels hourly for 4-6h to match the 4-6h duration of regular insulin when given IV. D50 IV boluses only last around one hour.

Management of Hyperkalemia With Insulin and Glucose: Pearls for the Emergency Clinician. J Emerg Med. 2019 May 11. pii: S0736-4679(19)30250-1. doi: 10.1016/j.jemermed.2019.03.043. [Epub ahead of print]

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