Potassium Levels Pose Treatment Challenges with Diabetes Comorbidities

Expert panel addresses barriers to and advancements in achieving optimal hyperkalemia management aiming to improve outcomes regarding kidney disease and cardiovascular events in in patients with diabetes.

with Peter McCullough, MD, MPH, and George Bakris, MD

Hyperkalemia is both prevalent and often recurrent in those patients with diabetes who also have diagnosed heart failure (HF), chronic kidney disease and /or hypertension.1

Effectiveness management of these patients is complicated by the use of standard medications to treat these common comorbidities as they have a tendency to cause elevated serum potassium as well as raising the risk of hyperkalemia occurring time and again.

Treating high potassium in people with diabetes can be tricky but is very necessary to avoid complications.

Hyperkalemia Management is Complex—Goal is to Avoid Too Little, Too Late

Long-term solutions are needed, said experts at presenting at the Cardiometabolic Health Congress in Chicago, Illinois. While there is a need to be attentive to hyperkalemia, an equally important challenge is the challenge facing clinicians to resist a typical hesitation to treat these concurrent diabetes complications for fear of patients developing hyperkalemia, said panelist Peter McCullough, MD, MPH, FACC, FACP, FAHA, FCCP, FNKF, professor of medicine and program director for the cardiovascular disease fellowship at Baylor University Medical Center, Dallas.

Often, the possibility that hyperkalemia may present is on a physician's mind, Dr. McCullough said, and while this consequence may not have manifest yet, ''there is the ongoing fear that it will arise" And that concern, he said, may translate into less than optimal care, such as backing off on the dose of renin-angiotensin-aldosterone system (RAASi) therapy.

Dr. McCullough and the other panel members explored the issue of managing hyperkalemia and the best approaches with elaboration and perspective provided by the symposium chair, George Bakris, MD, professor of medicine and director of the American Heart Association Comprehensive Hypertension Center at the University of Chicago in Illinois.  

Granted, a cautious approach is warranted given that the potential effects of hyperkalemia are serious, even deadly. Potassium concentrations above the upper limit of normal (5.0 mEq/L) have become more frequent in endocrine and cardiovascular practices, Dr. McCullough told EndocrineWeb. That is attributable to the growing population of patients with chronic kidney disease (CKD) and the broader use of drugs that modulate potassium excretion.2

Untreated hyperkalemia, when severe, may result in sudden cardiac death. Traditionally, management of elevated potassium has included decreasing dietary potassium, discontinuing potassium supplements, withdrawal of exacerbating drugs and acute treatment with IV calcium gluconate, insulin and glucose as well as correction of acidosis with sodium bicarbonate for short-term shifts out of the plasma pool and GI ion exchange with oral sodium polystyrene sulfonate in sorbitol. The latter, he mentioned from findings in a recent publication, is mainly given in the hospital and is poorly tolerated due to adverse gastrointestinal effects.2

When acute hyperkalemia arises, patients typically report muscle cramps and weakness, sometimes progressing to paralysis. Other symptoms include: drowsiness, hypotension, changes in the EKG, dysrhythmias, abdominal cramping, diarrhea and oliguria.1

Among reasons for hyperkalemia to manifest, Dr. McCullough said, are the common comorbid risk factors, including CKD and heart failure, RAASi therapy and potassium-sparing diuretics.1

Importance of RAASI Therapy in Diabetes Patients at Risk of HF and CKD

Renin-angiotensin-aldosterone system therapy in those with CKD, diabetes, and heart failure with preserved ejection fraction (HRrEF) was presented in guidelines by several professional organizations, including the American Heart Association, American College of Cardiology, and American Diabetes Association

[Slide Guidelines on RAASi].

One consequence that should be anticipated in patients with diabates who either discontinue or receive suboptimal RAASi therapy is an increased risk of renal and cardiovascular adverse events. Dr. McCullough said.  Based on findings published in 2015,3 he said that when patients with CKD, HF and DM were evaluated together, more than 34% of those who discontinued RAASi had adverse outcomes or mortality, compared to less than one in four patients who had received the maximum dose or even a sub-maximum dose.

"In effect, if we could get patients to a higher dose of RAASi, they would have much better kidney and CV outcomes," he said.

The potassium binder polystyrene sulfate (Kayexalate, Klonex) has been around since 1958, and there are two newer therapeutics: patiromer (Veltassa), from Relypsa, and the more recently approved sodium zirconium cyclosilicate (Lokelma), from AstraZeneca. "Both cof these newer drugs can be given to patients once a day," Dr. McCullough said.

The takeaway message for clinicians, he said, is to resist the response to managing patients with hyperkalemia by reducing RAASi as this is linked to poor cardiorenal outcomes.1

In a related report, researchers from Portugal, France and the United States focused on implementation issues regarding prescribing practices for potassium binders to prevent hyperkalemia in patients diagnosed with heart failure.3

The authors wrote that the new drugs ''have been suggested as potentially beneficial by allowing the maintenance (or increase) of the dose of medications that improve outcomes ion several cardiovascular conditions, but which have in common the propensity for raising serum potassium."

They continued: "However, potassium binding drugs have yet to prove their causal association with improvement in patents' prognosis before their widespread use can be recommended."3

Newer Potassium Binders Are Better Tolerated, Permit Less Dietary Restriction

The newer potassium binders have benefits over the first approved drug therapy, said Dr. Bakris. "They are much better tolerated," he said, “and they can be taken daily."4

Also, regarding use of the new binding agents, he said, they afford patients a bit more latitude with their dietary choices, allowing for a more liberal intake of foods high in potassium. Still, he said, patients must still be cautioned that food intake will not be a free ride, as he put it, a ''24/7 vegetable and fruit diet." Even so, Dr. Bakris said, he believes many doctors may not be prescribing the newer drugs.

Having quizzed colleagues, he found them lacking in this knowledge, he said. What is also needed, Dr. Bakris told EndocrineWeb, is education for our patients (even for some clinicians) regarding the potassium contents of various foods. Endocrinologists rarely talk to their patients about this, he said, often leaving it up to a dietitian, if the patient is referred and follows through.

Given this, he stresses the need for practitioners to commit to increasing your awareness of high potassium-containing foods so you are prepared to inform your patients about foods to avoid but with some understanding of tailoring recommendations to fit individual dietary needs. You might print out to share The Academy of Nutrition and Dietetics provides a useful list of potassium levels in common foods, which you can print out or direct your patients to view.

Another barrier for patients is cost. He acknowledged much higher price for the newer potassium binders. While generic sodium polystyrene sulfonate is about $7 for 120 ml, Veltassa can cost over $800 for 30 packets and Lokelma over $650 for 30 packets,5 according to prices listed on GoodRx. However, with insurance reimbursement, these costs may drop to permit a more affordable copay, Dr. Bakris said.

Dr. McCullough is a consultant to Astra Zeneca and Dr.Bakris consults for both Relypsa and Astra Zeneca. The symposium was jointly sponsored by the Postgraduate Institute for Medicine and the CMHC, with educational grants from AstraZeneca and Relypsa, manufacturers of the newer potassium binding agents.

Continue Reading:
Choosing Treatments: Optimizing Care in Patients with Diabetes and CVD
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