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
| Parameter | 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 7.9%, p=0.02) Similar potassium reductions in both groups |
| McNicholas et al., 2018 | Single center, retrospective (n=99) | Evaluate hypoglycemia risk based on usage of hyperkalemia protocol | Subgroup analysis showed trend towards hypoglycemia with higher doses of insulin in ESRD. (5 units: 28% vs 10 units: 54%) |
| LaRue et al., 2017 | Single center, retrospective (n=675) | 5 units vs 10 units IV regular insulin | Hypoglycemia was significantly increased in patients receiving 10 units of insulin (28.6 vs 19.5%, 95% CI −16.8% to −1.3%) No significant difference in potassium decrease |
| Pierce et al., 2015 | Single center, retrospective (n=149) | 5 units vs. 10 units with low eGFR | No significant difference in hypoglycemia between those receiving 10 units or 5 units of insulin (19.7 vs 16.7%) |
| Apel et al., 2014 | Single center, retrospective (n=221) | Hypoglycemia risk in patients receiving IV regular insulin (4–10 units) in patients with ESRD on HD | 90% of patients received 10 units of insulin 13% of patients experienced hypoglycemia (IV insulin doses not specified) Patients who were not diabetic had a higher risk of hypoglycemic events (OR 2.3, 95% CI 1.0–5.1, p=0.05) |
| Schafers et al., 2012 | Single center, retrospective (n=89) | Evaluated evidence of hypoglycemia in any patient receiving 5–10 units regular insulin | 61 patients had renal insufficiency (69%) 19 patients had hypoglycemia (21%) 15/19 patients who became hypoglycemic had renal insufficiency (79%) |
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
- 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.
- Insulin human regular. Lexicomp [online database]. Hudson, OH. Woltes Kluwer Clinical Drug Information, Inc. Accessed 2020, February 8.
- Verdier, et al. Aust Crit Care. 2021;S1036-7314(21)00070-9.
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.
from http://www.micromedexsolutions.com/
http://www.online.lexi.com
A short weekly clinical Pearl for acute care pharmacists.
Get the Friday Pearl email
Get a short weekly clinical Pearl for acute care pharmacists. No spam.
Free forever. Unsubscribe anytime. No spam.