Insulin therapy in the treatment of hyperkalaemia
Date First Published:
June 25, 2011
Last Updated:
August 16, 2011
Report by:
Jennifer Wright, Medical Student (University of Manchester)
Three-Part Question:
In [adults (>16 years) presenting to the emergency department with hyperkalaemia] is [intravenous insulin] effective at [lowering serum K+ levels]?
Clinical Scenario:
A 50- year old woman is referred to the Emergency Department by her GP with a serum potassium level of 6.4 mmol/L. A repeat blood test confirms hyperkalaemia, with a serum potassium of 6.8 mmol/L. After giving a cardiac membrane stabiliser you order an IV infusion of insulin and glucose, but wonder how effective this will be in lowering her serum potassium.
Search Strategy:
Cochrane Library for Systematic Reviews: May 2011
MEDLINE using OVID interface: 2003 to June week 2 2011
EMBASE: 2003 to 2011 week 24. Reviewed week 26.
Cumulative Index to Nursing and Allied Health Literature (CINAHL) Plus: 1947 to June 26th 2011
MEDLINE using OVID interface: 2003 to June week 2 2011
EMBASE: 2003 to 2011 week 24. Reviewed week 26.
Cumulative Index to Nursing and Allied Health Literature (CINAHL) Plus: 1947 to June 26th 2011
Search Details:
COCHRANE: hyperkalaemia, hyperkalemia, hyperkal*, hyperpotass*, potassium and hyperpotassaemia
MEDLINE: [exp Potassium/ OR exp Hyperkalemia/ OR hyperkalaemia.mp/ OR high potassium.mp/ OR hyperkal$.mp/ OR hyperpotass$.mp] AND [insulin.mp/ or exp Insulin/] Limit to (english language and humans and yr="2003 -Current")
EMBASE: [exp Potassium/ OR exp Hyperkalemia/ OR hyperkalaemia.mp/ OR high potassium.mp/ OR hyperkal$.mp/ OR hyperpotass$.mp] AND [insulin.mp/ or exp Insulin/] Limit to (human and english language and adult <18 to 64 years> and yr="2003 -Current")
CINAHL: [Hyperkalaemia/ OR Hyperkalemia/ OR Potassium /OR High Potassium/ OR Hyperkal*/ OR Hyperpotass*] AND [Insulin] Limit to (human and english language)
MEDLINE: [exp Potassium/ OR exp Hyperkalemia/ OR hyperkalaemia.mp/ OR high potassium.mp/ OR hyperkal$.mp/ OR hyperpotass$.mp] AND [insulin.mp/ or exp Insulin/] Limit to (english language and humans and yr="2003 -Current")
EMBASE: [exp Potassium/ OR exp Hyperkalemia/ OR hyperkalaemia.mp/ OR high potassium.mp/ OR hyperkal$.mp/ OR hyperpotass$.mp] AND [insulin.mp/ or exp Insulin/] Limit to (human and english language and adult <18 to 64 years> and yr="2003 -Current")
CINAHL: [Hyperkalaemia/ OR Hyperkalemia/ OR Potassium /OR High Potassium/ OR Hyperkal*/ OR Hyperpotass*] AND [Insulin] Limit to (human and english language)
Outcome:
COCHRANE:51 papers found, one of which was relevant.
MEDLINE: 317 papers found, none of which were considered relevant.
EMBASE: 568 papers found, one of which was relevant.
CINAHL: 182 papers found, 2 of which were relevant.
After removing duplicates a total of 3 relevant papers were found.
MEDLINE: 317 papers found, none of which were considered relevant.
EMBASE: 568 papers found, one of which was relevant.
CINAHL: 182 papers found, 2 of which were relevant.
After removing duplicates a total of 3 relevant papers were found.
Relevant Paper(s):
| Study Title | Patient Group | Study type (level of evidence) | Outcomes | Key results | Study Weaknesses |
|---|---|---|---|---|---|
| Emergency interventions for hyperkalaemia Mahoney BA, Smith WA, Lo D, Tsoi K, Tonelli M, Clase C 2005 Canada. | 2 RCTs and 2 randomised prospective cross-over trials. | Systematic review. 1a | Serum potassium concentration. | Insulin with glucose effective at lowering serum K+ by 15 minutes in studies which assessed this time point, and by 30 minutes in all studies. | Detailed results of these studies not shown. |
| Treatment of hyperkalemia with salbutamol and insulin. Mushtaq MA, Masood M 2006 Pakistan | 15 patients with ARF or CRF with a serum potassium > 6 mmol/L. Group B (5 patients) received glucose 25 grams diluted in 100ml of water over 15 minutes and 10 units of insulin as a bolus. | Prospective interventional cohort. 2b | Serum potassium concentration (mmol/L) | 0 minutes : 6.5 ± 0.3. 30 minutes: 5.9 ± 0.2. 60 minutes: 5.7 ± 0.2. 180 minutes: 5.9 ± 0.2. 360 minutes: 6.0 ± 0.2. | No sample size estimates performed and sample size was very small. Only patients with renal failure included. |
| Albuterol and insulin for treatment of hyperkalemia in hemodialysis patients. Allon M, Copkney C. 1990 USA | 12 HD patients with a serum K+ >5.0mmol/L. Insulin 10U bolus followed by glucose 50ml of a 50% solution IV over 5mins. | Randomised prospective cross-over design. 1b. |
Reduction in serum K+ concentration (mmol/L) | 15 mins: approx. 0.45 (P<0.001 Vs baseline.) 30 mins: approx. 0.58 45 mins: approx. 0.62 60 mins: 0.65± 0.09. | Approximations as results read from diagram and not supplied in text. No sample size estimates performed. Small sample size. Only HD patients included. |
Author Commentary:
There is some high level evidence supporting the use of IV insulin and dextrose in the management of hyperkalaemia. From these studies it can be seen that insulin effectively reduces serum K+ levels within 15 minutes and reaches maximum effect at 60 minutes.
However, it is important to note that these studies only consider the use of insulin in patients with renal failure and the sample sizes used are small.
However, it is important to note that these studies only consider the use of insulin in patients with renal failure and the sample sizes used are small.
Bottom Line:
Insulin with glucose is an effective treatment in the emergency management of hyperkalaemia.
References:
- Mahoney BA, Smith WA, Lo D, Tsoi K, Tonelli M, Clase C. Emergency interventions for hyperkalaemia
- Mushtaq MA, Masood M. Treatment of hyperkalemia with salbutamol and insulin.
- Allon M, Copkney C. . Albuterol and insulin for treatment of hyperkalemia in hemodialysis patients.