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Rafique Z, Budden J, Quinn CM, Duanmu Y, Safdar B, Bischof JJ, Driver BE, Herzog CA, Weir MR, Singer AJ, Boone S, Soto-Ruiz KM, Peacock WF. Patiromer utility as an adjunct treatment in patients needing urgent hyperkalaemia management (PLATINUM): design of a multicentre, randomised, double-blind, placebo-controlled, parallel-group study. BMJ Open 2023; 13:e071311. [PMID: 37308268 PMCID: PMC10277034 DOI: 10.1136/bmjopen-2022-071311] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2023] [Accepted: 05/11/2023] [Indexed: 06/14/2023] Open
Abstract
INTRODUCTION Hyperkalaemia is common, life-threatening and often requires emergency department (ED) management; however, no standardised ED treatment protocol exists. Common treatments transiently reducing serum potassium (K+) (including albuterol, glucose and insulin) may cause hypoglycaemia. We outline the design and rationale of the Patiromer Utility as an Adjunct Treatment in Patients Needing Urgent Hyperkalaemia Management (PLATINUM) study, which will be the largest ED randomised controlled hyperkalaemia trial ever performed, enabling assessment of a standardised approach to hyperkalaemia management, as well as establishing a new evaluation parameter (net clinical benefit) for acute hyperkalaemia treatment investigations. METHODS AND ANALYSIS PLATINUM is a Phase 4, multicentre, randomised, double-blind, placebo-controlled study in participants who present to the ED at approximately 30 US sites. Approximately 300 adult participants with hyperkalaemia (K+ ≥5.8 mEq/L) will be enrolled. Participants will be randomised 1:1 to receive glucose (25 g intravenously <15 min before insulin), insulin (5 units intravenous bolus) and aerosolised albuterol (10 mg over 30 min), followed by a single oral dose of either 25.2 g patiromer or placebo, with a second dose of patiromer (8.4 g) or placebo after 24 hours. The primary endpoint is net clinical benefit, defined as the mean change in the number of additional interventions less the mean change in serum K+, at hour 6. Secondary endpoints are net clinical benefit at hour 4, proportion of participants without additional K+-related medical interventions, number of additional K+-related interventions and proportion of participants with sustained K+ reduction (K+ ≤5.5 mEq/L). Safety endpoints are the incidence of adverse events, and severity of changes in serum K+ and magnesium. ETHICS AND DISSEMINATION A central Institutional Review Board (IRB) and Ethics Committee provided protocol approval (#20201569), with subsequent approval by local IRBs at each site, and participants will provide written consent. Primary results will be published in peer-reviewed manuscripts promptly following study completion. TRIAL REGISTRATION NUMBER NCT04443608.
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Affiliation(s)
- Zubaid Rafique
- Henry JN Taub Department of Emergency Medicine, Baylor College of Medicine, Houston, Texas, USA
| | | | | | - Youyou Duanmu
- Department of Emergency Medicine, Stanford University School of Medicine, Stanford, California, USA
| | - Basmah Safdar
- Department of Emergency Medicine, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Jason J Bischof
- Department of Emergency Medicine, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Brian E Driver
- Department of Emergency Medicine, Hennepin County Medical Center, Minneapolis, Minnesota, USA
| | - Charles A Herzog
- Division of Cardiology, Department of Internal Medicine, Hennepin Healthcare/University of Minnesota, Minneapolis, Minnesota, USA
| | - Matthew R Weir
- Department of Medicine, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Adam J Singer
- Department of Emergency Medicine, SUNY Stony Brook, Stony Brook, New York, USA
| | - Stephen Boone
- Henry JN Taub Department of Emergency Medicine, Baylor College of Medicine, Houston, Texas, USA
| | | | - W Frank Peacock
- Department of Emergency Medicine, Baylor College of Medicine, Houston, Texas, USA
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Long DS, Kelly MA, Lim SH. Risk factors, prevention and treatment of hypoglycaemia after hyperkalaemia in adult patients using intravenous insulin: An integrative review. Int J Nurs Pract 2023; 29:e13080. [PMID: 35859317 DOI: 10.1111/ijn.13080] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2022] [Revised: 06/02/2022] [Accepted: 06/27/2022] [Indexed: 02/04/2023]
Abstract
AIM An integrative review was conducted to synthesize published evidence on the prevention and treatment of hypoglycaemia and patient risk factors, in adult patients treated for hyperkalaemia with intravenous insulin and dextrose. METHODS This review followed the framework by Whittemore and Knafl. Papers included were limited to English language studies involving participants who were aged 18 years and above and admitted in the inpatient acute care and emergency departments. The literature search was performed using five electronic databases (CINAHL, Embase, PubMed, Proquest and Cochrane). RESULTS A total of 22 studies were included. Two main themes were derived-patient risk factors and prevention-intervention strategies. Five main patient risk factors were lower pretreatment blood glucose (<7 mmol/L), lower weight, renal insufficiencies, older age and nondiabetic. The four subthemes in the prevention-intervention strategies included (i) methods of administration and dosing of intravenous insulin and dextrose, (ii) frequency of blood glucose monitoring, (iii) education to healthcare professionals and (iv) rescue agents. CONCLUSIONS Standardized computerized order sets and integrated decision tool that can advise appropriate prescription of a higher volume of dextrose or lower insulin dose according to patient risk factors, regular monitoring and reinforced education may prevent and mitigate the risk of hypoglycaemia.
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Affiliation(s)
| | - Michelle A Kelly
- Clinical and Health Sciences, University of South Australia, Adelaide, Australia, Australia.,Clinical & Health Sciences, UniSA - East Campus, Adelaide, Australia.,Curtin School of Nursing, Curtin University, Perth, Australia
| | - Siew Hoon Lim
- Division of Nursing, Singapore General Hospital, Singapore
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Evaluation of Care Outcomes of Patients Receiving Hyperkalemia Treatment With Insulin in Acute Care Tertiary Hospital Emergency Department. J Emerg Nurs 2023; 49:99-108. [PMID: 36266095 DOI: 10.1016/j.jen.2022.09.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2022] [Revised: 09/04/2022] [Accepted: 09/14/2022] [Indexed: 12/13/2022]
Abstract
INTRODUCTION Treatment of hyperkalemia using intravenous insulin can result in severe hypoglycemia, but regular blood glucose monitoring is not standardized. This study aimed to (i) explore the demographics of adult patients receiving hyperkalemia treatment and (ii) identify the incidence rate of hypoglycemia and associated demographic or clinical characteristics. METHODS A descriptive design with prospective data collection was used. This study recruited 135 patients who received hyperkalemia treatment in the emergency department. Structured blood glucose monitoring was conducted at 1, 2, 4, and 6 hours after receiving intravenous insulin. Univariate analyses of association between demographic and clinical variables and hypoglycemia outcome were performed. RESULTS There were 31 hypoglycemic events, with 11.9%, 7.4%, 2.2%, and 1.5% occurring at the 1, 2, 4, and 6 hours after treatment. The logit regression showed no significantly increased risk of hypoglycemia in terms of the demographic and clinical variables. DISCUSSION The variation in blood glucose response observed in this study combined with the high incidences of hypolycaemia indicated the need for frequent and longer duration of monitoring for patients who were being treated for hyperkalaemia with IDT.
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Pollack K, Manning KR, Balassone J, Bui C, Taylor DM, Taylor SE. Response to Re: Hyperkalaemia in the emergency department: Epidemiology, management and monitoring of treatment outcomes. Emerg Med Australas 2022; 34:844-845. [PMID: 35785520 DOI: 10.1111/1742-6723.14042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2022] [Accepted: 06/13/2022] [Indexed: 11/27/2022]
Affiliation(s)
| | - Kiri R Manning
- Emergency Department, Middlemore Hospital, Auckland, New Zealand
| | | | - Calista Bui
- Pharmacy Department, Austin Health, Melbourne, Victoria, Australia
| | - David McD Taylor
- Emergency Department, Austin Health, Melbourne, Victoria, Australia.,Department of Medicine, The University of Melbourne, Melbourne, Victoria, Australia
| | - Simone E Taylor
- Pharmacy Department, Austin Health, Melbourne, Victoria, Australia
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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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Aljabri AM, Alsulami SA. Frequency of serum blood glucose monitoring after hyperkalaemia treatment using insulin and dextrose. J Taibah Univ Med Sci 2021; 17:82-86. [PMID: 35140569 PMCID: PMC8802856 DOI: 10.1016/j.jtumed.2021.07.014] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2021] [Revised: 07/13/2021] [Accepted: 07/25/2021] [Indexed: 11/30/2022] Open
Abstract
Objectives In patients with hyperkalaemia, dextrose is administered alongside insulin treatment to prevent hypoglycaemia. However, the incidence of hypoglycaemia in the first 6 hours following this regimen remains high, and frequent blood glucose monitoring is essential. This study evaluates the frequency of blood glucose monitoring following this insulin regimen. Methods This retrospective, multicentre study evaluated adult patients (≥18 years) who had been hospitalised for hyperkalaemia (K ≥ 5 mEq/mL) and managed using intravenous insulin and dextrose. We excluded patients if dextrose was not administered within 60 minutes of insulin therapy. The primary outcome was the frequency of serum blood glucose monitoring within 6 hours of the regimen. Secondary outcomes were the time between insulin treatment and follow-up measurements, and the incidence of hypoglycaemia (blood glucose <70 mg/dL). Results In total, 521 hyperkalaemia episodes were available for analysis; 192 (36.9%) had at least one reported follow-up measurement, 30 had at least two follow-up measurements (5.8%), and six had at least three follow-up measurements (1.2%). The median times of obtaining the first, second, and third blood glucose measurements were 3 h (interquartile range [IQR]: 1.7–4 h), 3.9 h (IQR: 3.2–5.1 h), and 4 h (IQR: 3.2–5.1 h), respectively. The incidence of hypoglycaemia among the episodes with follow-up was 4.8%. Conclusions The frequency of serum blood glucose monitoring following insulin therapy was low and inconsistent. This study emphasised the importance of adopting protocols incorporating more frequent blood glucose monitoring.
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Affiliation(s)
- Ahmed M. Aljabri
- Department of Pharmacy Practice, Faculty of Pharmacy, King Abdulaziz University, Jeddah, KSA
- Corresponding address: Department of Pharmacy Practice, Faculty of Pharmacy, King Abdulaziz University, Jeddah, KSA.
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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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