A Brief Review of the Pharmacology of Hyperkalemia: Causes and Treatment

James M. Wooten, PharmD; Fernanda E. Kupferman, MD; Juan C. Kupferman, MD, MPH


South Med J. 2019;112(4):228-233. 

In This Article

Other Considerations

Drug Interactions

As previously noted, hyperkalemia is much more common in patients with many comorbidities who take many medications. Drug interactions can be a common problem in the setting of hyperkalemia. Many of the drugs listed in Supplemental Digital Content Table 2, (http://links.lww.com/SMJ/A142) are commonly combined, and those combinations may potentiate the risk of hyperkalemia.[11,26,27] An excellent example of this includes combining an ACE inhibitor (eg, lisinopril) or an ARB (eg, losartan) with a nonsteroidal anti-inflammatory drug (eg, ibuprofen, naproxen). Both of these drug classes have been shown to potentiate the risk of hyperkalemia separately. In addition, both drug classes potentiate the risk of developing renal dysfunction. Drug-induced renal dysfunction combined with drug-induced hyperkalemia can lead to severe issues with potassium homeostasis. Conditions such as this must be monitored closely.[11,26,27]

Another common example of a potential drug interaction problem is the use of several of the drugs listed in Supplemental Digital Content Table 2, (http://links.lww.com/SMJ/A142) to treat congestive heart failure. This disease is common in older adult patients, and first-line therapies for systolic heart failure include loop diuretics (eg, furosemide), ACE inhibitors or ARBs, and β-adrenergic blockers. Many of these drug classes may potentiate hyperkalemia and/or renal dysfunction. In addition, therapy with loop diuretics may include potassium supplementation. The risk for developing hyperkalemia in patients with congestive heart failure can be high and this necessitates proper monitoring to prevent patient mortality.[11,26,27]

Hyperkalemia in Pediatric Patients

As with most disease states, treating hyperkalemia in pediatric patients is somewhat different from that in adults. The normal potassium ranges for children are slightly different from those in adults. These normal ranges are based on patient age, as follows:

  • Preterm: 3.0–6.0 mEq/L

  • Newborn: 3.7–5.9 mEq/L

  • Infant: 4.1–5.3 mEq/L

  • Child: 3.4–4.7 mEq/L

As with adults, hyperkalemia in children is defined as having a potassium value above the upper limit of the reference ranges listed above. Although hyperkalemia in children is less commonly seen than hypokalemia, it can be serious, and many of the dangerous consequences of hyperkalemia described in adults also can be encountered when potassium is elevated in a child.[25] As with adults, the higher serum potassium value and the rate of the elevation will influence the severity of the symptomatology. Cardiac arrhythmias are the predominant concern, and hyperkalemia must be treated quickly to avoid negative outcomes. Other clinical manifestations of hyperkalemia may include weakness, confusion, and muscular or respiratory paralysis.[28–31]

Many of the same conditions listed in Supplemental Digital Content Table 1, (http://links.lww.com/SMJ/A142) and the drugs listed in Supplemental Digital Content Table 2, (http://links.lww.com/SMJ/A142) may cause hyperkalemia in the pediatric patient. Renal function assessment is an important consideration, as it is in adults. The concept of pseudohyperkalemia also can occur in children, commonly via hemolysis of the blood sample.[28–31]

The more common pediatric drug doses for treating hyperkalemia in children are listed in Supplemental Digital Content Table 3, (http://links.lww.com/SMJ/A142). The reader is encouraged to double-check these doses against a current drug reference or with a pharmacist.[28–31]