Treatment	Mechanism of action	Dose	Comments
Intravenous calcium	Stabilizes cardiac membrane by rapid reduction of excitatory effects of potassium in cardiac tissue membrane	1,000 to 2,000 mg calcium gluconate over two to five minutes 500 to 1,000 mg calcium chloride over two to five minutes May repeat dose after five minutes if electrocardiography changes persist or recur; then every 30 to 60 minutes as needed	No effect on serum potassium levels Continuous cardiac monitoring required Adverse effects of calcium chloride include phlebitis and tissue necrosis Adverse effects of calcium chloride and calcium gluconate include hypercalcemia, arrhythmia, bradycardia, hypotension, and cardiac arrest
Regular insulin	Drives extracellular potassium into the cells	10 units intravenous bolus  and 25 g of glucose (50 mL of 50% dextrose); administer 50 g (100 mL of 50% dextrose) of glucose if initial glucose level < 100 mg per dL (5.55 mmol per L); administer additional 25 g of glucose (50 mL of 50% dextrose) if serum glucose < 70 mg per dL (3.89 mmol per L) Glucose administration may not be needed if initial glucose > 200 mg per dL (11.10 mmol per L) Monitor glucose hourly for at least three hours	0.6 to 1.2 mEq per L at one hour Onset of action: < 15 minutes Duration of effect: two hours Synergistic effect if administered with beta agonists Adverse effects include hypoglycemia; monitor every 30 minutes in the first hour, then hourly, and treat with dextrose if serum glucose < 70 mg per dL
Beta2- adrenergic agonists	Drive extracellular potassium into the cells	10 to 20 mg via nebulizer	0.6 mEq per L within 30 minutes after 10-mg inhaled dose 1.0 mEq per L one hour after 20-mg inhaled dose Duration of effect: two hours Synergistic effect if given with insulin Adverse effects include tachycardia
Sodium bicarbonate*	Drives extracellular potassium into the cells	Intravenous, continuous: 150 mEq in 1 L of 5% dextrose in water over two to four hours; normal saline may increase serum potassium and should not be used Intravenous, intermittent: 50 mEq over five minutes	Only beneficial in patients with metabolic acidosis; do not use in patients with end-stage renal disease Serum potassium decrease by 2 mEq per L for every 10 mEq per L increase in bicarbonate levels Adverse effects: hypernatremia, cardiac failure
Diuretics	Remove potassium from the body	No universally recommended dosage for acute or chronic hyperkalemia Typical initial dosages for edema:  Furosemide: 20 to 40 mg once or twice per day (intravenous or orally)  Bumetanide: 0.5 to 1 mg once or twice per day (intravenous or orally)  Torsemide: 10 to 20 mg once per day orally	Effect dependent on urine output; unpredictable kaliuretic effect Use with caution in patients who are hypovolemic or with renal impairment; if needed for severe acute hyperkalemia, consider a crystalloid infusion before administration of dose Adverse effects: hypovolemia, acute kidney injury
Gastrointestinal cation exchanger
Sodium zirconium cyclosilicate (Lokelma)	Removes potassium from the body	Acute: 10 g orally three times per day for 48 hours (total of six doses) Chronic: 10 g orally three times per day for 48 hours, followed by 10 g once per day; can adjust to 5 g once every other day to 15 g once per day	Decrease by 0.67 mEq per L at 48 hours Administer other oral medications at least two hours before or after a dose Adverse effect: urinary tract infection (1.1%), edema (0.9%)
Patiromer (Veltassa)	Removes potassium from the body	Acute and chronic: 8.4 g orally per day; titrate up to 16.8 to 25.2 g per day	Decrease serum potassium by 0.70 mEq per L after four weeks Administer other oral medications three hours before or after a dose Adverse effects include constipation (7.6%), diarrhea (4.5%), hypomagnesemia (7.1%)
Sodium polystyrene sulfonate	Removes potassium from the body	15 g orally one to four times per day 30 to 50 g rectally every six hours in retention enema	Serum potassium reduction from 0.8 to 1.4 mEq per L based on dose and duration Avoid concomitant administration with oral medications; significant drug interactions may occur Adverse effects include ischemic colitis, intestinal necrosis, intestinal perforation