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Cook ME, Tran LK, DeGrado JR, Alkazemi A, Marino KK. Evaluation of Insulin Dosing Strategies for Hyperkalemia Management at an Academic Medical Center. Clin Ther 2024; 46:382-388. [PMID: 38594106 DOI: 10.1016/j.clinthera.2024.03.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2023] [Revised: 03/03/2024] [Accepted: 03/08/2024] [Indexed: 04/11/2024]
Abstract
PURPOSE While intravenous (IV) insulin is often administered at a fixed dose of 10 units for acute hyperkalemia, optimal dosing for minimizing hypoglycemia while effectively reversing hyperkalemia has not been established. The purpose of this analysis was to evaluate the effect of insulin dosing strategies on hypoglycemia in patients with hyperkalemia. METHODS Adult patients presenting to an academic medical center who received IV insulin for hyperkalemia between 2016 and 2020 were retrospectively identified. Patients treated with 10 units of insulin (fixed) were compared to those who received < 10 units (reduced). The primary outcome was the incidence of hypoglycemia (blood glucose < 70 mg/dL) within 12 hours of insulin administration. Secondary outcomes included the incidence of severe hypoglycemia (blood glucose < 40 mg/dL) and change in potassium. Multivariable analyses were used to assess for risk factors for hypoglycemia and severe hypoglycemia. FINDINGS Of the 2576 patients included, 305 (11.8%) received reduced dosing and 2271 (88.2%) received fixed dosing. Hypoglycemia occurred in 16.7% of the reduced group and 15.9% of the fixed group (P = 0.70). Severe hypoglycemia occurred in 2.3% of the reduced group and 2.5% of the fixed group (P = 0.86). Median potassium reduction from baseline to first check post-insulin was less with reduced dosing (-0.6 mEq/L vs -0.8 mEq/L, P < 0.001). On multivariable regression analysis, greater weight-based insulin dose and ED location were significant predictors for hypoglycemia and severe hypoglycemia. Location in the intensive care unit was associated with a decreased risk of hypoglycemia. Higher pre-insulin glucose was protective for hypoglycemia and severe hypoglycemia. IMPLICATIONS The incidence of hypoglycemia was similar among both groups. Greater weight-based insulin dose was a significant risk factor for hypoglycemia, while higher baseline glucose levels were associated with a decreased risk, indicating that patient-specific insulin dosing for hyperkalemia may be warranted.
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Affiliation(s)
- Meghan E Cook
- Department of Pharmacy, Brigham and Women's Hospital, Boston, Massachusetts.
| | - Lena K Tran
- Department of Pharmacy, Brigham and Women's Hospital, Boston, Massachusetts; Department of Pharmacy, AdventHealth Central Florida, Kissimmee, Florida
| | - Jeremy R DeGrado
- Department of Pharmacy, Brigham and Women's Hospital, Boston, Massachusetts
| | - Afrah Alkazemi
- Department of Pharmacy, Brigham and Women's Hospital, Boston, Massachusetts; Department of Pharmacy Practice, College of Pharmacy, Kuwait University, Kuwait City, Kuwait
| | - Kaylee K Marino
- Department of Pharmacy, Brigham and Women's Hospital, Boston, Massachusetts
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Roach SN, Fletcher ML, Sarangarm P. A Retrospective Analysis of Intravenous Insulin versus Insulin and Nebulized Albuterol for the Treatment of Hyperkalemia in the Emergency Department. J Clin Pharmacol 2024; 64:619-625. [PMID: 38100157 DOI: 10.1002/jcph.2396] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2023] [Accepted: 12/10/2023] [Indexed: 01/10/2024]
Abstract
There is limited literature evaluating the use of nebulized albuterol in the management of hyperkalemia. The objective was to evaluate the efficacy of insulin alone compared with the addition of nebulized albuterol for the treatment of hyperkalemia. This is a retrospective, single-center evaluation of adult patients with hyperkalemia attending the Emergency Department of a large urban academic medical center. Consecutive patients with a potassium level of >5 mmol/L were included. Patients without a repeat potassium level within 4 hours of medication administration, those receiving hemodialysis before a repeat serum potassium, or those that had a hemolyzed blood sample were excluded. The primary outcome was the change in potassium level within 4 hours in patients who received insulin monotherapy versus patients who received insulin and albuterol. The secondary outcomes included hospital length of stay, intensive care unit (ICU) admission, and mortality. Out of the 204 patients, 141 received insulin, whereas 63 received insulin and nebulized albuterol. There was no difference in the change in potassium level between the insulin and the insulin and nebulized albuterol groups (0.85 ± 0.6 vs 0.96 ± 0.78 mmol/L; P = .36). There was no difference in median hospital length of stay (8.6 days, IQR 13.2 days, vs 5.6 days, IQR 8.2 days; P = .09), ICU admission (31.9% vs 38.1%; P = .39), and all-cause mortality (14.9% vs 17.5%; P = .64). In this retrospective analysis, the addition of albuterol to insulin for the treatment of hyperkalemia did not result in a greater change in potassium level within 4 hours of therapy.
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Affiliation(s)
- Sara N Roach
- University of New Mexico College of Pharmacy, Albuquerque, NM, USA
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Dybdahl D, Roberson T, Rasor E, Kline L, Pershing M. Impact of a Hyperkalemia Protocol Tailored to Glucose Concentration and Renal Function on Insulin-Induced Hypoglycemia in Patients with Low Pretreatment Glucose. J Emerg Med 2024; 66:e421-e431. [PMID: 38462394 DOI: 10.1016/j.jemermed.2023.12.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2023] [Revised: 12/01/2023] [Accepted: 12/08/2023] [Indexed: 03/12/2024]
Abstract
BACKGROUND Hyperkalemia is a common electrolyte abnormality that requires urgent treatment. Insulin is an effective treatment for hyperkalemia, but risk factors for developing insulin-induced hypoglycemia exist (e.g., low pretreatment glucose or renal impairment). OBJECTIVE This study evaluated the impact of a hyperkalemia protocol tailored to glucose concentration and renal function on insulin-induced hypoglycemia. METHODS This was a retrospective cohort study of emergency department patients with glucose ≤ 100 mg/dL treated with insulin for hyperkalemia. The primary outcome was incidence of hypoglycemia in patients treated prior to (July 1, 2018-June 30, 2019) vs. after (January 1, 2020-December 31, 2020) the protocol update, which individualized insulin and dextrose doses by glucose concentration and renal function. Secondary outcomes included change in potassium and protocol safety. We assessed factors associated with hypoglycemia using multiple logistic regression. RESULTS We included 202 total patients (preimplementation: 114, postimplementation: 88). Initial insulin dose was lower in the postimplementation group (p < 0.001). We found a nonsignificant reduction in hypoglycemia in the postimplementation group (42.1% vs. 30.7%, p = 0.10). Degree of potassium reduction was similar in patients who received insulin 5 units vs. 10 units (p = 0.72). Higher pretreatment glucose (log odds ratio [OR] -0.05, 95% confidence interval [CI] -0.08 to -0.02) and additional insulin administration (log OR -1.55, 95% CI -3.01 to -0.25) were associated with reduced risk of developing hypoglycemia. CONCLUSION A hyperkalemia protocol update was not associated with a significant reduction in hypoglycemia, and the incidence of hypoglycemia remained higher than anticipated. Future studies attempting to optimize treatment in this high-risk population are warranted.
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Affiliation(s)
- Daniel Dybdahl
- Department of Pharmacy, OhioHealth Grant Medical Center, Columbus, Ohio
| | - Taylor Roberson
- Department of Pharmacy, OhioHealth Grant Medical Center, Columbus, Ohio
| | - Emily Rasor
- Department of Pharmacy, OhioHealth Grant Medical Center, Columbus, Ohio
| | - Laura Kline
- Department of Pharmacy, OhioHealth Riverside Methodist Hospital, Columbus, Ohio
| | - Michelle Pershing
- Department of Research, OhioHealth Research Institute, Columbus, Ohio
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Weant KA, Gregory H. Acute Hyperkalemia Management in the Emergency Department. Adv Emerg Nurs J 2024; 46:12-24. [PMID: 38285416 DOI: 10.1097/tme.0000000000000504] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2024]
Abstract
Acute hyperkalemia is characterized by high concentrations of potassium in the blood that can potentially lead to life-threatening arrhythmias that require emergent treatment. Therapy involves the utilization of a constellation of different agents, all targeting different goals of care. The first, and most important step in the treatment of severe hyperkalemia with electrocardiographic (ECG) changes, is to stabilize the myocardium with calcium in order to resolve or mitigate the development of arrythmias. Next, it is vital to target the underlying etiology of any ECG changes by redistributing potassium from the extracellular space with the use of intravenous regular insulin and inhaled beta-2 agonists. Finally, the focus should shift to the elimination of excess potassium from the body through the use of intravenous furosemide, oral potassium-binding agents, or renal replacement therapy. Multiple nuances and controversies exist with these therapies, and it is important to have a robust understanding of the underlying support and recommendations for each of these agents to ensure optimal efficacy and minimize the potential for adverse effects and medication errors.
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Affiliation(s)
- Kyle A Weant
- Department of Clinical Pharmacy and Outcomes Sciences, College of Pharmacy, University of South Carolina, Columbia (Dr Weant); and Department of Pharmacy, University of North Carolina Health, Chapel Hill (Dr Gregory)
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Chothia MY, Humphrey T, Schoonees A, Chikte UME, Davids MR. Hypoglycaemia due to insulin therapy for the management of hyperkalaemia in hospitalised adults: A scoping review. PLoS One 2022; 17:e0268395. [PMID: 35552566 PMCID: PMC9097985 DOI: 10.1371/journal.pone.0268395] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2022] [Accepted: 04/28/2022] [Indexed: 12/22/2022] Open
Abstract
Introduction Hyperkalaemia is a very common electrolyte disorder encountered in hospitalised patients. Although hypoglycaemia is a frequent complication of insulin therapy, it is often under-appreciated. We conducted a scoping review of this important complication, and of other adverse effects, of the treatment of hyperkalaemia in hospitalised adults to map existing research on this topic and to identify any knowledge gaps. Materials and methods We followed the PRISMA-ScR guidelines. Studies were eligible for inclusion if they reported on any adverse effects in hospitalised patients ≥18-years-old, with hyperkalaemia receiving treatment that included insulin. All eligible research from 1980 to 12 October 2021 were included. We searched Medline (PubMed), Embase (Ovid), the Cochrane Library, CINHAL, Africa-Wide Information, Web of Science Core Collection, LILACS and Epistemonikos. The protocol was prospectively registered with the Open Science Framework (https://osf.io/x8cs9). Results Sixty-two articles were included. The prevalence of hypoglycaemia by any definition was 17.2% (95% CI 16.6–17.8%). The median timing of hypoglycaemia was 124 minutes after insulin administration (IQR 102–168 minutes). There were no differences in the prevalence of hypoglycaemia when comparing insulin dose (<10 units vs. ≥10 units), rate of insulin administration (continuous vs. bolus), type of insulin (regular vs. short-acting) or timing of insulin administration relative to dextrose. However, lower insulin doses were associated with a reduced prevalence of severe hypoglycaemia (3.5% vs. 5.9%, P = 0.02). There was no difference regarding prevalence of hypoglycaemia by dextrose dose (≤25 g vs. >25 g); however, prevalence was lower when dextrose was administered as a continuous infusion compared with bolus administration (3.3% vs. 19.5%, P = 0.02). The most common predictor of hypoglycaemia was the pre-treatment serum glucose concentration (n = 13 studies), which ranged from < 5.6–7.8 mmol/L. Conclusion This is the first comprehensive review of the adverse effects following insulin therapy for hyperkalaemia. Hypoglycaemia remains a common adverse effect in hospitalised adults. Future randomised trials should focus on identifying the optimal regimen of insulin therapy to mitigate the risk of hypoglycaemia.
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Affiliation(s)
- Mogamat-Yazied Chothia
- Division of Nephrology, Department of Medicine, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
- * E-mail:
| | - Toby Humphrey
- Division of Experimental Medicine and Immunotherapeutics, Department of Medicine, University of Cambridge, Cambridge, United Kingdom
| | - Anel Schoonees
- Centre for Evidence-based Health Care, Division of Epidemiology and Biostatistics, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Usuf Mohamed Ebrahim Chikte
- Department of Global Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Mogamat Razeen Davids
- Division of Nephrology, Department of Medicine, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
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Finder SN, McLaughlin LB, Dillon RC. 5 versus 10 Units of Intravenous Insulin for Hyperkalemia in Patients With Moderate Renal Dysfunction. J Emerg Med 2022; 62:298-305. [PMID: 35058093 DOI: 10.1016/j.jemermed.2021.10.027] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2021] [Revised: 09/26/2021] [Accepted: 10/12/2021] [Indexed: 10/19/2022]
Abstract
BACKGROUND A reduced dose of 5 units of intravenous (i.v.) insulin has been widely accepted for treatment of hyperkalemia in those with end-stage renal dysfunction. However, there remains a dearth of data for patients with moderate renal dysfunction (estimated glomerular filtration rate 15-59 mL/min/m2). OBJECTIVE Describe the incidence of hypoglycemia and relative change in serum potassium when using 5 vs. 10 units of insulin for hyperkalemia in patients with moderate renal dysfunction. METHODS This was a single-center, retrospective study evaluating adult patients with moderate renal dysfunction who received i.v. insulin for treatment of hyperkalemia. Patients were analyzed based on whether they received 5 or 10 units of i.v. insulin. The primary outcome was the rate of hypoglycemia in each group. Secondary outcomes included rate of relative potassium-lowering effect and incidence of severe hypoglycemia. RESULTS Hypoglycemia occurred in 12 patients who received 5 units of i.v. insulin and 16 patients who received 10 units of i.v. insulin (6.5% vs. 8.4%, p = 0.476). Serum potassium was significantly reduced when utilizing 10 units over 5 units of i.v. insulin (-0.9 mmol/L vs. -0.63 mmol/L, p = 0.001). Severe hypoglycemia was seen in two encounters in both the 5-unit and 10-unit groups (1.1% vs. 1.0%, p = 0.979). CONCLUSION There was no difference in hypoglycemic events among patients with moderate renal dysfunction receiving 5 vs. 10 units of i.v. insulin for hyperkalemia. However, 10 units of i.v. insulin lowered serum potassium significantly more than 5 units of i.v. insulin.
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Affiliation(s)
- Sydney N Finder
- Department of Pharmaceutical Services, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Linda B McLaughlin
- Department of Pharmaceutical Services, Vanderbilt University Medical Center, Nashville, Tennessee.
| | - Ryan C Dillon
- Department of Pharmaceutical Services, Vanderbilt University Medical Center, Nashville, Tennessee
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Verdier M, DeMott JM, Peksa GD. A comparison of insulin doses for treatment of hyperkalaemia in intensive care unit patients with renal insufficiency. Aust Crit Care 2021; 35:258-263. [PMID: 34167889 DOI: 10.1016/j.aucc.2021.05.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2020] [Revised: 04/26/2021] [Accepted: 05/09/2021] [Indexed: 01/15/2023] Open
Abstract
BACKGROUND Hyperkalaemia is a complication in patients with chronic kidney disease or acute kidney injury and occurs frequently in the intensive care unit. One treatment approach includes intravenous (IV) insulin to shift potassium intracellularly. OBJECTIVES The primary outcome was hypoglycaemia (blood glucose <70 mg/dL) after insulin administration. Secondary outcomes included change in serum potassium levels and incidence of severe hypoglycaemia. METHODS This was a single-centre, retrospective study evaluating critically ill adult patients with chronic kidney disease stage III-V, end-stage renal disease, or acute kidney injury who received IV insulin for treatment of hyperkalaemia from March 2008 to September 2018. Patients were divided into two insulin-dosing regimen groups: 5 units or 10 units. RESULTS Of the 174 patients included, hypoglycaemia after insulin administration occurred in eight of 87 patients (9.2%) in the 5-unit group and 17 of 87 patients (19.5%) in the 10-unit group (p = 0.052). There was no difference in rates of severe hypoglycaemia or change in serum potassium levels. CONCLUSIONS In critically ill patients requiring treatment for hyperkalaemia, a lower dose of IV insulin does not result in lower statistically significant rates of hypoglycaemia. However, lower insulin doses provide a similar potassium-lowering effect and cause a meaningful decrease in hypoglycaemic episodes. Intensive care unit providers may consider 5 units of IV insulin over 10 units although further larger controlled studies are needed.
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Affiliation(s)
- Miranda Verdier
- Department of Pharmacy, Rush University Medical Center, Chicago, IL, USA
| | - Joshua M DeMott
- Department of Pharmacy, Rush University Medical Center, Chicago, IL, USA; Department of Emergency Medicine, Rush University Medical Center, Chicago, IL, USA
| | - Gary D Peksa
- Department of Pharmacy, Rush University Medical Center, Chicago, IL, USA; Department of Emergency Medicine, Rush University Medical Center, Chicago, IL, USA.
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Moussavi K, Garcia J, Tellez-Corrales E, Fitter S. Reduced alternative insulin dosing in hyperkalemia: A meta-analysis of effects on hypoglycemia and potassium reduction. Pharmacotherapy 2021; 41:598-607. [PMID: 33993515 DOI: 10.1002/phar.2596] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2021] [Revised: 04/01/2021] [Accepted: 04/18/2021] [Indexed: 11/08/2022]
Abstract
STUDY OBJECTIVE Recent studies have identified that reduced alternative intravenous insulin doses, such as 5 units or 0.1 units/kg, may reduce the risk of hypoglycemia compared to standard doses of 10 units in patients treated for hyperkalemia. However, some studies suggest that these alternative doses may reduce the ability to lower serum potassium. This study was performed to determine the impact of alternative insulin dosing on hypoglycemia and potassium reduction in patients with hyperkalemia. DESIGN Meta-analysis. DATA SOURCE PubMed/MEDLINE, CENTRAL, Ovid, and ClinicalTrials.gov were searched from inception through November 2020. PATIENTS Patients treated with standard (10 units) or alternative (<10 units) insulin dosing strategies for hyperkalemia. Only studies that evaluated hypoglycemia (serum glucose <70 mg/dl), severe hypoglycemia (serum glucose <50 mg/dl), and potassium reduction post-treatment were included in the meta-analysis. All articles were assessed for bias using the Cochrane Risk of Bias Assessment Tool and Newcastle-Ottawa scales for randomized prospective trials and retrospective trials, respectively. INTERVENTION None. MEASUREMENTS AND MAIN RESULTS Ten retrospective cohort studies (n = 3437) were included and had low- or moderate-risk of bias. Alternative insulin dosing strategies included 5 units, 0.1 units/kg, and <10 units. Alternative dosing had lower pooled odds of hypoglycemia (odds ratio [OR] 0.55, 95% confidence interval [CI] 0.43-0.69, I2 = 8%) and severe hypoglycemia (OR 0.41, 95% CI 0.27-0.64, I2 = 0%). No difference in potassium reduction was detected (mean difference -0.02 mmol/L, 95% CI -0.11-0.07, I2 = 53%). CONCLUSIONS Alternative insulin dosing strategies for hyperkalemia management resulted in less hypoglycemia and severe hypoglycemia without compromising potassium reduction compared to standard dose. Prospective studies are needed to confirm these findings.
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Affiliation(s)
- Kayvan Moussavi
- Department of Pharmacy Practice, Marshall B. Ketchum University College of Pharmacy, Fullerton, California, USA
| | - Joshua Garcia
- Department of Pharmacy Practice, Marshall B. Ketchum University College of Pharmacy, Fullerton, California, USA
| | - Eglis Tellez-Corrales
- Department of Pharmacy Practice, Marshall B. Ketchum University College of Pharmacy, Fullerton, California, USA
| | - Scott Fitter
- Emergency Medicine, Loma Linda University Medical Center, Loma Linda, California, USA.,Loma Linda University School of Pharmacy, Loma Linda, California, USA
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