Comparison of Potassium Binders in the ER
Comparison of Potassium Binders in the ER
Compare efficacy of 3 oral potassium binders (cation exchange resins) on lowering blood
 potassium, in patients presenting to the Emergency Room with acute hyperkalemia.
Adult patients presenting to the Emergency Room at UC Irvine with plasma potassium >5.5 mEq/L
 (who meet inclusion/exclusion criteria and provide written informed consent) will be
 randomized to a one-time dose of one of the following oral medications:

 1. Sodium polystyrene sulfate (SPS)

 2. Patiromer (Veltassa)

 3. Sodium zirconium cyclosilicate (Lokelma)

 4. Nonspecific laxative: polyethylene glycol 3350 (MiraLax)

 Participants will receive standard-of-care hyperkalemia therapy as well.

 Blood potassium will be checked at 2 and 4 hours after dose of study drug. Participants will
 complete a symptom and palatability questionnaire at 4 hours.

 The purpose of this research study is to determine the effects of various potassium binders
 (SPS, patiromer, zirconium) vs a non-specific laxative (MiraLax) in the Emergency Room for
 patients found to have elevated blood potassium > 5.5 mEq/L. Hyperkalemia is a fairly common
 electrolyte disorder with varying levels of severity. Moderate hyperkalemia is in the range
 5.5-5.9 mEq/L while severe hyperkalemia is ≥6.0 mEq/L or if patient is symptomatic: muscle
 weakness/paralysis or with EKG changes (e.g., peaked T waves, widening QRS, arrhythmias
 including ventricular fibrillation or asystole). Hyperkalemia is most commonly associated
 with kidney insufficiency, metabolic acidosis, and the use of medications such as
 renin-angiotensin-aldosterone system inhibitors.

 In an emergency, the main goal is to reverse adverse cardiac effects and shift potassium into
 cells using interventions such as insulin/glucose and albuterol. However, these are only
 temporary measures. To remove potassium from the body, agents or interventions that may be
 used include cation exchange resins (potassium binders), loop diuretics, or dialysis. For
 over 50 years the only available oral cation exchange resin has been sodium polystyrene
 sulfonate. In recent years, two new agents (patiromer and zirconium) have been approved by
 the FDA for chronic management of hyperkalemia.

 The cation exchange resins have not been studied head-to-head for acute hyperkalemia. This is
 a critical knowledge gap since acute hyperkalemia poses a significant burden on the
 healthcare system. In claims data analysis of 80,000 patients, half with hyperkalemia and
 half without, the patients with hyperkalemia had 4 times higher rate of inpatient admissions,
 7 times longer average length of stay, and 30-day hospital readmission rate 14.21% vs 9.86%
 in the non-hyperkalemia cohort. The findings from our study will help inform decision-making
 guidelines for the treatment of acute hyperkalemia.
Inclusion Criteria:

 -  Plasma potassium > 5.5 mEq/L

 -  Age ≥18 years

 -  Patient able to provide written informed consent

 Exclusion Criteria:

 -  Recent bowel surgery

 -  Ileus or bowel obstruction

 -  Pseudohyperkalemia signs and symptoms, such as excessive fist clenching, hemolyzed
 blood specimen, severe leukocytosis or thrombocytosis

 -  Pregnancy

 -  Active psychiatric disorder

 -  Diabetic ketoacidosis or hyperkalemia caused by any condition for which a therapy
 directed against the underlying cause of hyperkalemia would be a better treatment
 option

 -  Dialysis session expected within 4 hours after randomization

 -  History of hypersensitivity to sodium polystyrene sulfonate resin or patiromer

 -  Concurrent use of sorbitol (due to increased risk of intestinal necrosis when used
 with sodium polystyrene sulfonate)