Letter to the Editor
OK, kayexalate is dead. (“Kayexalate is Really, Most Sincerely Dead,” by Dan Runde, MD; EMN. 2019;41:1; http://bit.ly/2yte3Wv.)
Assuming we use all the other recommended medications for treating hyperkalemia, what would Dr. Runde recommend as a replacement for kayexalate with a similar mechanism?
Scott M. Russo, DO
Dr. Runde responds: This is a good question, and unfortunately, the answer is, it depends.
I assume we're talking about patients with stable hyperkalemia (asymptomatic, no ECG changes, etc.). If that's the case, then it's not clear we need to do anything from the ED. If the patient has normal renal function, then it's about keeping him hydrated and potentially adding diuretics to aid in excreting potassium through the urine. (Loop diuretics are a good place to start.)
But if you're asking about GI excretion, there are a couple of new kids on the block, patiromer and sodium zirconium cyclosilicate (ZS-9). Unlike kayexalate, these medications actually do decrease serum potassium levels. On the other hand, patiromer has a black box warning that it can't be given within six hours of other oral medications, and ZS-9 looks like it might be associated with increased UTIs and edema in about one percent of patients.
I'm all for helping our inpatient and outpatient colleagues, but when it comes to hyperkalemia, I'd recommend managing the emergent cases, aiding in urinary excretion when possible, and leaving the initiation of these new GI excretion agents alone.