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|BECAUSE OF REPORTS OF INTESTINAL AND GASTRIC ULCERATION AND BLEEDING WITH EXTENDED-RELEASE POTASSIUM CHLORIDE PREPARATIONS, THESE DRUGS SHOULD BE RESERVED FOR THOSE PATIENTS WHO CANNOT TOLERATE OR REFUSE TO TAKE LIQUIDS OR EFFERVESCENT POTASSIUM PREPARATIONS OR FOR PATIENTS IN WHOM THERE IS A PROBLEM OF COMPLIANCE WITH THESE PREPARATIONS.|
Dave's key factors (reduce risk of acute GI
ER Tablets/capsules: Each manufacturer of an extended dosage form (K-Dur tablets, Micro-K capsules, etc), states that the maximum single dose is 20 meq. Higher dosages should be given in divided doses. Example order: K-Dur 80 meq x 1. Recommendation: change to K-Dur 20 meq q2h x 4 doses.
Oral Solutions: Very little support for doses above 50meq (given as a single dose). Must dilute solution based on manufacturer's recommendations.
If using immediate release preparations (KCl powder, soln or IV dose), a level should be checked no sooner than 60 minutes. If using a sustained release product, a level should be checked no sooner than 3 hours. Levels should be checked for each 60meq of K+ administered.
Direct quotes from reference above:
Peripheral administration: Maximum concentration via peripheral line is 10 mEq/100 ml. The maximum infusion rate via peripheral line is 10 mEq per hour. In neonates and pediatrics, the maximum infusion rate via peripheral line is 0.5 - 1 meq/kg/hour.
Central administration: Preferred concentration via central line is 20 mEq/100 ml. The maximum concentration for fluid restricted patients is 20 mEq/50 ml. In adults, the maximum amount of KCl available in each IV minibag is 20 mEq. The maximum infusion rate via central line is 20 mEq/hr. In neonates and pediatrics, the maximum infusion rate via central line is 1 meq/kg/hour.
Monitoring: potassium levels must be checked after a total of 60 mEq has been administered. Potassium levels must be checked no sooner than 60 minutes after a given IV dose. In neonates and pediatrics, potassium levels must be checked after a total of 1 meq/kg has been administered.
Maintenance: Adult doses from 40-100 mEq/day may be required for potassium repletion given in 2 - 4 divided doses per day. In the neonate and pediatric patient, 1-3 meq/kg/day may be required for potassium repletion given in 2 - 4 divided doses per day. In adults, start with 20-40 mEq/day and titrate to desired level.
Dose / Maximum (acute): A 40 mEq dose may be given q2h for a max of 120 mEq within a 6 hour period. In the neonate, start with 0.5 - 1 meq/kg/day and titrate to desired level with the maximum dose of 3 meq/kg within a 6 hour period.
Maximum (oral + IV): When oral potassium therapy is combined with parenteral supplementation for adults, a maximum total dose (IV + PO) is 120 mEq within a 6 hour period. For the neonate, a maximum total dose (IV + PO) is 3 meq/kg within a 6 hour period.
Direct quotes from reference above:
Requirements: Normal daily requirements: Oral, IV: 40-80 mEq/day. Prevention of hypokalemia during diuretic therapy: Oral: 20-40 mEq/day in 1-2 divided doses.
Treatment of hypokalemia:
Potassium >2.5 mEq/L:
Oral: 60-80 mEq/day plus additional amounts if needed
IV: 10 mEq q1h prn.
Potassium <2.5 mEq/L:
Oral: Up to 40-60 mEq initial dose, followed by further doses based on lab values
IV: Up to 40 mEq over 1 hour, with doses based on frequent lab monitoring; deficits at a plasma level of 2 mEq/L may be as high as 400-800 mEq of potassium.
The usual dietary potassium intake by the
average adult is 50 to 100 mEq per day. Potassium depletion sufficient
to cause hypokalemia usually requires the loss of 200 or more mEq of
potassium from the total body store.
Dosage must be adjusted to the individual needs of each patient. The dose for the prevention of hypokalemia is typically in the range of 20 mEq per day.
Doses of 40-100 mEq per day or more are used for the treatment of potassium depletion. Dosage should be divided if more than 20 mEq per day is given such that no more than 20 mEq is given in a single dose. The dose should be taken after a meal.
Preparation: Each 20 mEq (one K-LOR mEq packet) of potassium should be dissolved in at least 4 oz cold water or juice.
Klor-Con®: immediately dispersing extended-release oral dosage form
containing 1500 mg of microencapsulated kcl equivalent to 20 mEq of K+
in a tablet.
Klor-Con® M15: 1125 mg =15 mEq of potassium in a tablet.
Klor-Con® M10: 750 mg = 10 mEq of potassium in a tablet.
These formulations are intended to slow the release of potassium so that the likelihood of a high localized concentration of potassium chloride within the gastrointestinal tract is reduced.
Klor-Con® M should be discontinued immediately and the possibility of ulceration, obstruction or perforation considered if severe vomiting, abdominal pain, distention or gastrointestinal bleeding occurs. Doses of 40-100 mEq per day or more are used for the treatment of potassium depletion. Dosage should be divided if more than 20 mEq per day is given such that no more than 20 mEq is given in a single dose.
INDICATIONS AND USAGE: BECAUSE OF REPORTS OF INTESTINAL AND GASTRIC ULCERATION AND BLEEDING WITH EXTENDED-RELEASE POTASSIUM CHLORIDE PREPARATIONS, THESE DRUGS SHOULD BE RESERVED FOR THOSE PATIENTS WHO CANNOT TOLERATE OR REFUSE TO TAKE LIQUID OR EFFERVESCENT POTASSIUM PREPARATIONS OR FOR PATIENTS IN WHOM THERE IS A PROBLEM OF COMPLIANCE WITH THESE PREPARATIONS. Gastrointestinal Lesions --Solid oral dosage forms of potassium chloride can produce ulcerative and/or stenotic lesions of the gastrointestinal tract. Based on spontaneous adverse reaction reports, enteric coated preparations of potassium chloride are associated with an increased frequency of small bowel lesions (40-50 per 100,000 patient years) compared to extended-release wax matrix formulations (less than one per 100,000 patient years).
|Potassium depletion sufficient to cause 1 mEq/L drop in serum potassium requires a loss of about 100-200 mEq of potassium from total body store. Available in liquid, powder, or tablet form. Any form may irritate the stomach and cause vomiting. Should be taken with food or after meals to minimize GI discomfort. All solid dosage forms of potassium supplements are contraindicated in any patient in whom there is cause for arrest or delay in tablet passage through the gastrointestinal tract. In these instances, potassium supplementation should be with a liquid preparation. Slow-release preparations should be avoided in patients at high risk for potassium chloride-induced gastrointestinal lesions, i.e., patients with cardiomegaly, esophageal stricture or compression, dysphagia, recent gastric surgery, delayed intestinal transit, ulcerative bowel disease or diverticulitis. Enteric coated tablets have an unacceptably high rate of gastrointestinal symptoms (40 to 50 incidents per 100 000 patient years) and should not be used.|
Medications Used in Acute Treatment of Hyperkalemia
Source: American Family Physician. Medications listed in order of
use from most to least urgent.
Dosage: 10 to 20 mL of 10 percent solution IV over two to three minutes.
Length of effect: 30 minutes
MOA: Protects myocardium from toxic effects of potassium; no effect on serum potassium level.
Cautions: Can worsen digoxin toxicity.
Dosage: Regular insulin 10 units IV with 50 mL of 50 percent glucose
Onset: 15 to 30 minutes
Length of effect: Two to six hours
MOA: Shifts potassium out of the vascular space and into the cells; no effect on total body potassium.
Cautions: Consider 5 percent dextrose solution infusion at 100 mL per hour to prevent hypoglycemia with repeated doses. Glucose unnecessary if blood sugar elevated above 250 mg per dL (13.9 mmol per L).
Dosage: 10 to 20 mg by nebulizer over 10 minutes (use concentrated form, 5 mg per mL).
Onset: 15 to 30 minutes
Length of effect: Two to three hours
MOA: Shifts potassium into the cells, additive to the effect of insulin; no effect on total body potassium.
Cautions: May cause a brief initial rise in serum potassium
Dosage: 20 to 40 mg IV, give with saline if volume depletion is a concern
Onset: 15 minutes to one hour
Length of effect: Four hours
MOA: Increases renal excretion of potassium
Cautions: Only effective if adequate renal response to loop diuretic.
Excretion of renal potassium can be increased with the use of diuretics, particularly loop diuretics (e.g., furosemide). Patients with decreased kidney function may be relatively resistant to the effects of diuretics. If the patient is volume depleted, saline can be given with the diuretic. Hemodialysis or continuous renal replacement therapy are the treatments of last resort, with the exception of patients already receiving these therapies.
Sodium polystyrene sulfonate (Kayexalate)
Dosage: Oral: 50 g in 30 mL of sorbitol solution. Rectal: 50 g in a retention enema.
Onset: One to two hours (rectal route is faster)
Length of effect: Four to six hours
MOA: Removes potassium from the gut in exchange for sodium
Cautions: Sorbitol may be associated with bowel necrosis. May lead to sodium retention.
Gastrointestinal excretion is accomplished using sodium polystyrene sulfonate (Kayexalate), which binds potassium in the colon in exchange for sodium; it can be given orally or as a retention enema. The enema form is faster; the oral route can take four to six hours because it requires the resin to get to the colon before it takes effect. Sodium polystyrene sulfonate often is given with sorbitol to decrease constipation. However, sorbitol can have intestinal complications, with reports of bowel necrosis and perforation in immunocompromised patients. Using furosemide (Lasix) with polystyrene reduces the risk of volume overload because of the sodium that is exchanged for potassium by the resin.
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