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Introduction

    • Insulin with dextrose is an effective method to lower potassium levels quickly in acute hyperkalemia.

    • Literature shows ranges of potassium reduction by 0.5-1.0 mEq after administration of a single dose.

    • Patients with renal insufficiency and end stage renal disease (ESRD) have a higher incidence of

    hypoglycemia after treatment with insulin for hyperkalemia due to:

    o Reduced insulin clearance (prolonged insulin action)

    o Reduced hepatic glucose production

    o Reduced renal gluconeogenesis

    • The appropriate dose of insulin to minimize hypoglycemic events when using for the treatment of

    hyperkalemia in patients with renal insufficiency is still debated.

Clinical Detail

    Medication

    Insulin (human regular)

    Mechanism

    Cause an intracellular shift of potassium via exchange of sodium ions via the Na+/K+ ATPase pump

    Dose

    5-10 units

    Doses of 0.1 units/kg (max 10 units) have also been considered

    Administration

    IV push

    PK/PD

    Onset: 15-30 minutes for initial potassium lowering effects

    Duration: 4-6 hours, prolonged duration in ESRD

    Adverse Effects

    Hypoglycemia, hypokalemia, hypersensitivity

    Compatibility

    Can dilute in normal saline to increase volume for ease of administration

    Pearls

    Must be given with dextrose (25g IV) to prevent hypoglycemia

    • Some patients require repeated dextrose; rare exceptions for those already extremely hyperglycemic

    The most common used product is regular human insulin given IV to ensure fast onset of potassium

    lowering effects and prevent variable absorption

Evidence

    Author,

    Year

    Design

    (Sample Size)

    Intervention &

    Comparison

    Outcomes

    Verdier et

    al., 2021

    Single center,

    retrospective

    (n =174)

    5 units vs 10 units IV regular

    insulin in ICU patients

  • Hypoglycemia was more frequent with 10 unit vs 5 units of

    • IV insulin (19.5 vs 9.2%, p=0.052)

  • No difference in rates of severe hypoglycemia or change

    • in serum potassium

    Moussavi et

    al., 2020

    Retrospective,

    observational

    (n=700)

    10 units vs <10 units IV regular

    insulin

  • Significantly lower frequency of hypoglycemia with lower

    • insulin doses (11.2 vs 17.6%, p=0.008)

  • Greater reduction in serum potassium with insulin doses

    • <10 units (mean reduction 0.94 vs 0.8, p=0.008)

    Keeney et

    al., 2019

    Single center,

    retrospective

    (n=442)

    5 units vs 10 units IV regular

    insulin

  • Hypoglycemic events in patients with reduced eGFR

    • were higher in patients receiving 10 units of insulin (17.4 vs

  • 9%, p=0.02)
  • Similar potassium reductions in both groups

    • McNicholas

    et al., 2018

Conclusions

    • Hypoglycemia risk seems to be elevated in those patients with renal insufficiency, especially those

    who are insulin-naive

    • Consideration should be made to lower the initial dose of IV insulin for patients with AKI or CKD

References

    • LaRue, et al. Pharmacotherapy. 2017;37(12):1516-1522.

    • Moussavi, et al. Crit Care Expl. 2020;2:e0092.

    • Allon, et al. Kidney Int 1990;38 (5):869-72. 7.

    • Allon, et al. Am J Kidney Dis 1996;28(4):508-14.

    • Li, et al. Clin Kidney J. 2014;7:239-41.

    • Schafers, et al. Journal of Hospital Medicine. 2012;7(3):239-42.

    • Pierce, et al. Annals of Pharmacotherapy. 2015;49(12).1322-26.

    • McNicholas, et al. Kidney Int Rep. 2018;3:328-36,

    • Apel, et al. Clin Kidney J. 2014;7(2)248-50.

  • Keeney, et al. Am J Emerg Med. 2019; doi.org/10.1016/j.ajem.2019.158374
  • Insulin Human Regular. Micromedex [Electronic version].Greenwood Village, CO: Truven Health Analytics. Accessed 2020, February 8.

    • from http://www.micromedexsolutions.com/

  • Insulin human regular. Lexicomp [online database]. Hudson, OH. Woltes Kluwer Clinical Drug Information, Inc. Accessed 2020, February 8.

    • http://www.online.lexi.com

  • Verdier, et al. Aust Crit Care. 2021;S1036-7314(21)00070-9.
Tags:hyperkalemia insulin renal insufficiency hypoglycemia

Source PDF

PFP – Insulin for hyperK in renal insufficiency.pdf