New Guidelines for Potassium Replacement in Clinical Practice

8/9/2019 New Guidelines for Potassium Replacement in Clinical Practice

1/18

Copyright 2000 by the American Medical Association. All Rights Reserved. Applicable

FARS/DFARS Restrictions Apply to Government se. American Medical Association!"#" $. State St! Chicago! %& '0'#0.

Volume 160(16) 11 September 2000 pp 2429-2436

New Guidelines for Potassium Replacement in Clinical Practice: AContemporary Review by the National Council on Potassium in

Clinical Practice[Review Article]

Co!" #$% &' * +owe%" ,eter R' * elto!" ,$ul +' * ,ri.$!t" /' ic$el

rom te ep$rtme!t o eici!e" !iver.it% o i!!e.ot$ eic$l Scool" i!!e$poli. (r Co!)*

ep$rtme!t o C$riolo%" /$!5e!$u o.pit$l $! eic$l Re.e$rc Ce!ter" %!!ewoo" ,$" $! ep$rtme!t

o eici!e" #eer.o! eic$l Collee" ,il$elpi$" ,$ (r +owe%)* ep$rtme!t o 7piemiolo%" 8ul$!e

!iver.it% Scool o ,ublic e$lt $! 8ropic$l eici!e" &ew rle$!." /$ (r elto!)* $! ep$rtme!t o

eici!e" eic$l Collee o :eori$" Auu.t$ (r ,ri.$!t)'

Repri!t.; #$% &' Co!" " C$riov$.cul$r ivi.io!" C


2/18

• 8$ble 1

• 8$ble 2

• 8$ble 3

• 8$ble 4

Abstract

8i. $rticle i. te re.ult o $ meeti! o te &$tio!$l Cou!cil o! ,ot$..ium i! Cli!ic$l

,r$ctice' 8e Cou!cil" $ multii.cipli!$r% roup compri.i! .peci$li.t. i! c$riolo%"

%perte!.io!" epiemiolo%" p$rm$c%" $! compli$!ce" w$. orme to e@$mi!e te

critic$l role o pot$..ium i! cli!ic$l pr$ctice' 8e o$l o te Cou!cil w$. to $..e.. te

role o pot$..ium i! term. o curre!t meic$l pr$ctice $! uture cli!ic$l $pplic$tio!.'

8e prim$r% outcome o te meeti! w$. te evelopme!t o uieli!e. or pot$..ium

repl$ceme!t ter$p%' 8e.e uieli!e. repre.e!t $ co!.e!.u. o te Cou!cil member.

$! $re i!te!e to provie $ e!er$l $ppro$c to te preve!tio! $! tre$tme!t o

%po5$lemi$'

Arc >!ter! e'2000*160;2429-2436

>! rece!t %e$r." .tuie. o te pote!ti$l p$toe!etic role o pot$..ium eicie!c% i!

v$riou. meic$l co!itio!. $ve u!er.core te import$!ce o preve!ti! or correcti!

ti. eicie!c%' Altou it $. lo! bee! e.t$bli.e t$t te m$i!te!$!ce o !orm$l.erum pot$..ium i. e..e!ti$l i! reuci! te ri.5 o lie-tre$te!i! c$ri$c $rr%tmi$."

$ccumul$ti! evie!ce .ue.t. t$t te i!cre$.e i!t$5e o pot$..ium c$! $l.o lower

bloo pre..ure $! reuce te ri.5 o .tro5e'

ew cli!ici$!. $ttempt to mo!itor $! $ume!t pot$..ium .tore. o! $ routi!e b$.i.' !e

re$.o! m$% be te i!co!ve!ie!ce o $ccur$tel% me$.uri! tot$l bo% pot$..ium" wic

e!t$il. $ 24-our uri!$r% collectio! r$ter t$! $ r$pi l$bor$tor% .erum me$.ureme!t'

A!oter re$.o! i. te pr$ctic$l iicult% o $cievi! $! m$i!t$i!i! optim$l

pot$..ium level.' 8ereore" m$!% cli!ici$!. m$% !ot $ttempt to reme% .ub!orm$l

pot$..ium level. e@cept i! i-ri.5 p$tie!t.'

8e curre!t l$c5 o co!.e!.u. o! ow to preve!t $! tre$t %po5$lemi$ $. le to te

!elect o $ wie r$!e o .itu$tio!. i! wic i!cre$.i! pot$..ium i!t$5e mit elp

preve!t .euel$e o c$riov$.cul$r i.e$.e' 8e multi$ctori$l $! i!ter$ctive

mec$!i.m. t$t $re .timul$te b% %perte!.io! $! eve! more .o b% e$rt $ilure"

wic m$!$te te i!trouctio! o ru. t$t i.rupt electrol%te omeo.t$.i." emp$.iBe

te .eriou. role o pot$..ium' 8i. $rticle review. co!tempor$r% ti!5i! o! pot$..ium

i! cli!ic$l pr$ctice'

te tot$l bo% pot$..ium co!te!t ($bout 3


3/18


4/18

,ot$..ium epletio! i. o!e o te mo.t commo! electrol%te $b!orm$litie. e!cou!tere

i! cli!ic$l pr$ctice' ore t$! 20 o o.pit$liBe p$tie!t. $ve %po5$lemi$" wiel%

ei!e $. $ .erum pot$..ium level o le.. t$! 3'< mmolD/' /ow .erum (or pl$.m$)

co!ce!tr$tio!. o pot$..ium m$% occur i! up to 40 o outp$tie!t. tre$te wit ti$Bie

iuretic.' 2

Hec$u.e te 5i!e%. $re te m$Eor reul$tor. o e@ter!$l pot$..ium omeo.t$.i."

$ccou!ti! or $ppro@im$tel% =0 o pot$..ium tr$!.it rom te bo%" re!$l %.u!ctio!

c$! re.ult i! ro.. $b!orm$litie. i! .erum pot$..ium level.' 1 8r$!.cellul$r pot$..ium

omeo.t$.i. epe!. to $ l$re e@te!t o! $ci-b$.e b$l$!ce' 1" 3 Acio.i. .timul$te.

cellul$r elu@ o pot$..ium rom cell." re.ulti! i! %per5$lemi$" were$. $l5$lo.i.

.timul$te. i!lu@ o pot$..ium" re.ulti! i! %po5$lemi$" witout $ .imult$!eou.

$lter$tio! i! tot$l bo% pot$..ium' >!cre$.e. i! i!.uli! or c$tecol$mi!e. c$! $l.o

.timul$te cell. to import pot$..ium $! e@port .oium' >! p$tie!t. wit t%pe 2 i$bete."

i!cre$.e. i! luco.e or i!.uli! c$! $ect pot$..ium omeo.t$.i.' Stimul$tio! o [bet$] 2-

$re!eric receptor. b% .%mp$tomimetic ru. (e" eco!e.t$!t. $!

bro!coil$tor.) c$! tempor$ril% reuce .erum pot$..ium' A .t$!$r o.e o !ebuliBe$lbuterol reuce. .erum pot$..ium b% 0'2 to 0'4 mmolD/' A .eco! o.e $mi!i.tere

witi! 1 our reuce. it b% $ppro@im$tel% 1 mmolD/' 2 [bet$]2-Hloc5$e" o! te oter

$!" i!cre$.e. .erum pot$..ium'

vert %po5$lemi$ m$% be i$!o.e we! te .erum pot$..ium level i. le.. t$! 3'6

mmolD/' ,ote!ti$l c$u.e. i!clue iuretic ter$p%" i!$eu$te iet$r% pot$..ium i!t$5e"

i iet$r% .oium i!t$5e" $! %pom$!e.emi$ (8$ble 2)' >! mo.t c$.e." %po5$lemi$

i. .eco!$r% to ru tre$tme!t" p$rticul$rl% iuretic ter$p% (8$ble 3)' 2 iuretic. i!ibit

clorie-$..oci$te .oium re$b.orptio! i! te 5i!e%" cre$ti! $ $vor$ble

electrocemic$l r$ie!t or pot$..ium .ecretio!' 2" 4 8e eree o %po5$lemi$ i.

irectl% rel$te to te o.e $! $l-lie o te iuretic $mi!i.tere'


5/18

8$ble 2' ,ote!ti$l C$u.e. o %po5$lemi$

8$ble 3' ru. 8$t >!uce %po5$lemi$G

$!$eme!t o %po5$lemi$ .oul bei! wit $ torou review o te p$tie!tI.

meic$l recor' > pot$..ium-w$.ti! ru. $re !ot implic$te" %po5$lemi$ i. mo.t

commo!l% c$u.e eiter b% $b!orm$l lo.. trou te 5i!e% i!uce b% met$bolic

$l5$lo.i. or b% lo.. i! te .tool .eco!$r% to i$rre$' 2

Hec$u.e pot$..ium i. $ m$Eor i!tr$cellul$r c$tio!" te ti..ue. mo.t .everel% $ecte b%

pot$..ium imb$l$!ce $re mu.cle $! re!$l tubul$r cell.' $!ie.t$tio!. o %po5$lemi$

i!clue e!er$liBe mu.cle we$5!e.." p$r$l%tic ileu." $! c$ri$c $rr%tmi$. ($tri$l

t$c%c$ri$ wit or witout bloc5" $triove!tricul$r i..oci$tio!" ve!tricul$r t$c%c$ri$"

$! ve!tricul$r ibrill$tio!)' 8%pic$l electroc$rior$pic c$!e. i!clue l$t or

i!verte 8 w$ve." S8-.eme!t epre..io!" $! promi!e!t w$ve.' >! .evere u!tre$te

%po5$lemi$" m%op$t% m$% prore.. to r$bom%ol%.i." m%olobi!uri$" $! $cute

http://gateway.ut.ovid.com/gw1/ovidweb.cgi#91%2391http://gateway.ut.ovid.com/gw1/ovidweb.cgi?View+Image=00000779-200009110-00001%7CTT3&S=IDNJHKJKCGLEAP00Dhttp://gateway.ut.ovid.com/gw1/ovidweb.cgi?View+Image=00000779-200009110-00001%7CTT2&S=IDNJHKJKCGLEAP00Dhttp://gateway.ut.ovid.com/gw1/ovidweb.cgi#91%2391


6/18

re!$l $ilure' Suc complic$tio!. $re mo.t ote! .ee! i! %po5$lemi$ .eco!$r% to

$lcooli.m'

PR!&CI'& #&C !# P!A""I$M

$t$ rom $!im$l e@perime!t. $! epiemioloic .tuie. .ue.t t$t i pot$..iumm$% reuce te ri.5 o .tro5e' Altou p$rt o te protective eect o pot$..ium m$%

be ue to loweri! o bloo pre..ure" $!$l%.i. o $!im$l moel. .ue.t. t$t pot$..ium

m$% $ve oter protective mec$!i.m." i!clui! i!ibitor% eect. o! ree r$ic$l

orm$tio!" v$.cul$r .moot mu.cle prolier$tio!" $! $rteri$l trombo.i.' 6-9 >t $. $l.o

bee! .ow! e@perime!t$ll% t$t pot$..ium m$% reuce m$crop$e $ere!ce to te

v$.cul$r w$ll ($! import$!t $ctor i! te evelopme!t o $rteri$l le.io!." o@i$tive .tre..

o te e!otelium" or v$.cul$r eico.$!oi prouctio!)' 10-12

>! 19=J" te re.ult. o $ 12-%e$r pro.pective popul$tio! .tu% (& K =>' 1J

>!irect .upport or ti. %pote.i. come. rom ob.erv$tio!. o te eect. o prim$r%

http://gateway.ut.ovid.com/gw1/ovidweb.cgi#95%2395http://gateway.ut.ovid.com/gw1/ovidweb.cgi#99%2399http://gateway.ut.ovid.com/gw1/ovidweb.cgi#102%23102http://gateway.ut.ovid.com/gw1/ovidweb.cgi#102%23102http://gateway.ut.ovid.com/gw1/ovidweb.cgi#95%2395http://gateway.ut.ovid.com/gw1/ovidweb.cgi#95%2395http://gateway.ut.ovid.com/gw1/ovidweb.cgi#95%2395http://gateway.ut.ovid.com/gw1/ovidweb.cgi#95%2395http://gateway.ut.ovid.com/gw1/ovidweb.cgi#95%2395http://gateway.ut.ovid.com/gw1/ovidweb.cgi#95%2395http://gateway.ut.ovid.com/gw1/ovidweb.cgi#95%2395http://gateway.ut.ovid.com/gw1/ovidweb.cgi#105%23105http://gateway.ut.ovid.com/gw1/ovidweb.cgi#106%23106http://gateway.ut.ovid.com/gw1/ovidweb.cgi#toc%23tochttp://gateway.ut.ovid.com/gw1/ovidweb.cgi#toc%23tochttp://gateway.ut.ovid.com/gw1/ovidweb.cgi#toc%23tochttp://gateway.ut.ovid.com/gw1/ovidweb.cgi#95%2395http://gateway.ut.ovid.com/gw1/ovidweb.cgi#99%2399http://gateway.ut.ovid.com/gw1/ovidweb.cgi#102%23102http://gateway.ut.ovid.com/gw1/ovidweb.cgi#102%23102http://gateway.ut.ovid.com/gw1/ovidweb.cgi#95%2395http://gateway.ut.ovid.com/gw1/ovidweb.cgi#95%2395http://gateway.ut.ovid.com/gw1/ovidweb.cgi#95%2395http://gateway.ut.ovid.com/gw1/ovidweb.cgi#95%2395http://gateway.ut.ovid.com/gw1/ovidweb.cgi#95%2395http://gateway.ut.ovid.com/gw1/ovidweb.cgi#95%2395http://gateway.ut.ovid.com/gw1/ovidweb.cgi#105%23105http://gateway.ut.ovid.com/gw1/ovidweb.cgi#106%23106


7/18

$lo.tero!i.m (e" $lo.tero!e-prouci! %perpl$.i$ or $e!om$) or .eco!$r%

$lo.tero!i.m (e" [email protected] i!e.tio! o licorice)' 8e.e .%!rome. $re c$r$cteriBe

b% $b!orm$ll% low .erum pot$..ium level. $! elev$te bloo pre..ure' Rever.$l o te

u!erl%i! c$u.e re.ult. i! i!cre$.e .erum pot$..ium level. $! ecre$.e bloo

pre..ure' Simil$rl%" correctio! o iuretic or l$@$tive $bu.e c$! $l.o r$i.e pot$..ium

level $! lower bloo pre..ure'

8e l$re-.c$le &ur.e.I e$lt Stu% (& K 41") i!clue i!cre$.e pot$..ium i!t$5e $. $

core recomme!$tio! or te preve!tio! $! tre$tme!t o %perte!.io!' 22

Amo! %perte!.ive p$tie!t." cert$i! .ubroup. woul erive .peci$l be!eit rom

i!cre$.e pot$..ium i!t$5e' He.t reco!iBe $re Aric$! Americ$!.' 23 >! te met$-

$!$l%.i. b% elto! et $l" 21 te reuctio! o .%.tolic bloo pre..ure $ter pot$..ium.uppleme!t$tio! w$. $ppro@im$tel% 3 time. re$ter i! bl$c5. comp$re wit wite.' >!

$itio!" .ever$l .tuie. $ve reve$le lower uri!$r% pot$..ium e@cretio! i! bl$c5. t$!

i! wite.' 23 $t.o! et $l 24 reporte t$t 24-our uri!$r% e@cretio! o pot$..ium w$. 2=

mmol i! bl$c5 em$le. $! 36 mmol i! wite em$le.' 8e uri!$r% .oium-to-pot$..ium

r$tio w$. 4'1 i! bl$c5. $! 2'9 i! wite." $ iere!ce t$t w$. .t$ti.tic$ll% .i!iic$!t' 24

8e Veter$!. Ami!i.tr$tio! Cooper$tive Stu% :roup o! A!ti%perte!.ive Ae!t. (&

K 623) ou! pot$..ium e@cretio! to be 62 ier i! wite. t$! i! bl$c5. (J3 N 41 v.

4< N 40 mmol)* i! $itio!" .erum pot$..ium level. were !e$tivel% $..oci$te wit

.%.tolic bloo pre..ure' 8e .tu% co!clue t$t te iere!ce i! uri!$r% pot$..ium

e@cretio! $! i! .erum pot$..ium level. betwee! bl$c5. $! wite. relecte $

iere!ce betwee! te 2 roup. i! te i!t$5e o iet$r% pot$..ium' Suc $ iere!cem$% be $! import$!t $ctor i! te re$ter prev$le!ce o %perte!.io! i! bl$c5.' 2


8/18

Clinical Implications in CHF

&ot .urpri.i!l%" pot$..ium epletio! i. commo!l% .ee! i! p$tie!t. wit C" $

co!itio! t$t i. c$r$cteriBe b% .ever$l p%.ioloic $b!orm$litie. t$t prei.po.e to

te evelopme!t o electrol%te i.turb$!ce.' Amo! te p$toe!etic $ctor. $..oci$te

wit C $re re!$l %.u!ctio! $! !euroormo!$l $ctiv$tio!" wic embr$ce.timul$tio! o te re!i!-$!iote!.i!-$lo.tero!e $@i." e!$!ce .%mp$tetic !ervou.

to!e" $! %per.ecretio! o c$tecol$mi!e.' 26

A commo! mi.perceptio! re$ri! $!iote!.i!-co!verti! e!B%me (AC7) i!ibitor

ter$p% i. t$t te.e ru. e!$!ce pot$..ium rete!tio!" tereb% elimi!$ti! te !ee to

$ pot$..ium or pot$..ium-.p$ri! iuretic. to AC7 i!ibitor ter$p%' >! m$!% c$.e."

te pre.cribe o.$e. o AC7 i!ibitor. i! p$tie!t. wit C $re i!.uicie!t to protect

$$i!.t pot$..ium lo..' Serum pot$..ium level." tereore" mu.t be clo.el% mo!itore i!

$ll p$tie!t. wit COeve! to.e t$5i! AC7 i!ibitor.Oto mi!imiBe te lie-

tre$te!i! ri.5 o %po5$lemi$ i! te.e p$tie!t.'

8e $rr%tmoe!ic pote!ti$l o io@i! i. e!$!ce b% %po5$lemi$ i! p$tie!t. wit

e$rt $ilure' e! u.i! io@i! i! combi!$tio! wit $ loop iuretic $! $! AC7

i!ibitor" te eci.io! o weter to $mi!i.ter pot$..ium .uppleme!t. c$! be comple@'

/eier et $l 26 recomme! m$i!t$i!i! .erum pot$..ium level. i! te r$!e betwee! 4'<

$!


9/18

>! te $b.e!ce o u!erl%i! e$rt i.e$.e" m$Eor $b!orm$litie. i! c$ri$c co!uctio!

.eco!$r% to %po5$lemi$ $re rel$tivel% u!u.u$l' owever" mil-to-moer$te

%po5$lemi$ c$! i!cre$.e te li5elioo o c$ri$c $rr%tmi$. i! p$tie!t. wo $ve

c$ri$c i.cemi$" e$rt $ilure" or let ve!tricul$r %pertrop%' 2" 29 A. me!tio!e

e$rlier" ti. occurre!ce i. !ot .urpri.i! i! lit o te import$!t role t$t pot$..ium

pl$%. i! te electrop%.ioloic propertie. o te e$rt' 8e rel$tio! betwee! e@tr$ $!i!tr$cellul$r pot$..ium level. i. te prim$r% etermi!$!t o te re.ti! membr$!e

pote!ti$l (R,)' C$!e. i! pot$..ium level moi% te electrop%.ioloic propertie.

o te membr$!e $! c$! $ve proou! eect. o! impul.e e!er$tio! $! co!uctio!

trouout te e$rt' 30

,ot$..ium eicie!c%" $. well $. pot$..ium c$!!el bloc5$e or ow!-reul$tio!" c$!

c$u.e prolo!e repol$riB$tio!" te p$toe!ic $ctor i! te e!e.i. o tor.$e. e

poi!te.' 8e eect. o %po5$lemi$ o! repol$riB$tio! $re m$!iie i! m$!% i.e$.e

.t$te." i!clui! let ve!tricul$r %pertrop%" C" m%oc$ri$l i.cemi$" $!

m%oc$ri$l i!$rctio!' Suc eect." i! tur!" $re compou!e b% $e!t. wit cl$.. >>>

$!ti$rr%tmic eect." .uc $. .ot$lol' 31

8e &er!.t eu$tio! e.cribe. ow te r$tio o i!tr$cellul$r to e@tr$cellul$r pot$..ium

$ect. te R, o m%oc$ri$l cell.; R, K M61'< lo [+ QiD+ Qe]' C$!e. i! ti. r$tio"

.uc $. to.e i!uce b% iuretic ter$p%" $ect c$ri$c co!uctio! $! $utom$ticit%'

A. $ re.ult" low i!tr$cellul$r pot$..ium level. c$! i!cre$.e .po!t$!eou. epol$riB$tio!"

$utom$ticit%" $! te emere!ce o ectopic oci' 32

e.pite ti. compelli! b$.ic i!orm$tio!" te li!5 betwee! %po5$lemi$ $! cli!ic$l

$rr%tmoe!e.i. i. !ot $ .tro! o!e' C$r$li. et $l 32 .tuie 1J %perte!.ive me! to

etermi!e te rel$tio!.ip o iuretic-i!uce %po5$lemi$ wit ve!tricul$r ectopic

$ctivit%' 8e% ou! t$t te ri.5 or ve!tricul$r ectopic $ctivit% w$. m$r5e i! $ roup

o p$tie!t. wo were oler $! $ cli!ic$l evie!ce o or$!ic e$rt i.e$.e' ,$tie!t.

wit te.e c$r$cteri.tic. $ i!cre$.e reue!c% $! comple@it% o ve!tricul$r ectopic

$ctivit% uri! iuretic ter$p%' >! te.e p$tie!t." !orm$liB$tio! o .erum pot$..ium

level. wit or$l pot$..ium .uppleme!t. or pot$..ium-.p$ri! $e!t. reuce te

comple@it% $! reue!c% o $rr%tmi$. b% =


10/18

impo.e $ .tricter .t$!$r or tre$tme!t (pot$..ium F4'0 mmolD/) e.peci$ll% i! p$tie!t.

wit e$rt i.e$.e wo $re $t ri.5 or .eriou. ve!tricul$r t$c%$rr%tmi$.' or e@$mple"

te ri.5 o e$rl% ve!tricul$r ibrill$tio! i! $cute m%oc$ri$l i!$rctio! i. .tri5i!l%

i!cre$.e i! p$tie!t. wit .erum pot$..ium level. le.. t$! 3'9 mmolD/' 34-3J owever"

tere $re !o $t$ to prove t$t $re..ive reple!i.me!t o pot$..ium i! p$tie!t. wit

e$rt i.e$.e !ece..$ril% le$. to $ better cli!ic$l outcome'

P!A""I$M "$PPL&M&NAI!N "RA&GI&":PR&'&NI!N '" R&PL&I!N

>!cre$.i! pot$..ium i!t$5e .oul be co!.iere we! .erum pot$..ium level. $re

betwee! 3'< $! 4'0 mmol' Altou tre$tme!t o $.%mptom$tic p$tie!t. wit

borerli!e or Plow !orm$lP co!ce!tr$tio!. i. co!trover.i$l" ver% low level. (F3'0 mmol)

$re u!iver.$ll% re$re $. u!e.ir$ble' 7ort. to i!cre$.e pot$..ium i!t$5e $re

$ppropri$te i! cert$i! popul$tio!. wo $re vul!er$ble to c$ri$c $rr%tmi$. (.uc $.

p$tie!t. wit e$rt $ilure" to.e t$5i! io@i!" $! p$tie!t. wit $ i.tor% om%oc$ri$l i!$rctio! or i.cemic e$rt i.e$.e)' e! te .erum pot$..ium level i.

below 3'< mmol" pot$..ium .uppleme!t$tio! m$% be w$rr$!te eve! i! $.%mptom$tic

p$tie!t. wit mil-to-moer$te %perte!.io!' 32

Str$teie. to mi!imiBe te ri.5 o pot$..ium epletio! i!clue mi!imiBi! te o.$e o

!o!Mpot$..ium-.p$ri! iuretic. $! re.tricti! .oium i!t$5e' >!cre$.i! iet$r%

pot$..ium i. te mo.t .tr$itorw$r me$!. o e!$!ci! pot$..ium i!t$5e" but te

i co!te!t o .ome pot$..ium-ric oo. i. $ pote!ti$l r$wb$c5 to iet$r% pot$..ium

.uppleme!t$tio! (8$ble 1)' oreover" iet$r% pot$..ium i. $lmo.t e!tirel% couple wit

po.p$te" r$ter t$! wit clorie* tereore" it i. !ot eective i! correcti! pot$..ium

lo.. t$t i. $..oci$te wit clorie epletio!" .uc $. i! iuretic ter$p%" vomiti!" $!!$.o$.tric r$i!$e' 2 or p$tie!t. receivi! iuretic ter$p%" $! $ttempt .oul be

m$e to reuce te o.e or to i.co!ti!ue ter$p%' > te pot$..ium epletio! i. !ot ue

to iuretic ter$p%" te p$tie!t .oul be ev$lu$te or oter c$u.e. o pot$..ium lo..' 1

e! iuretic ter$p% i. !ece..$r%" pot$..ium b$l$!ce .oul be protecte b% u.i!

low-o.e iuretic. $! b% u.i! iuretic. i! combi!$tio! wit ru. t$t $ve te

pote!ti$l or .p$ri! pot$..ium (.uc $. [bet$]-bloc5er." pot$..ium-.p$ri! iuretic."

AC7 i!ibitor." or $!iote!.i! receptor bloc5er.)' Repletio! .tr$teie. $l.o .oul

i!clue e$ti! oo. i i! pot$..ium" u.i! .$lt .ub.titute." or t$5i! pre.criptio!

pot$..ium .uppleme!t. (8$ble 4)' 2

http://gateway.ut.ovid.com/gw1/ovidweb.cgi#123%23123http://gateway.ut.ovid.com/gw1/ovidweb.cgi#123%23123http://gateway.ut.ovid.com/gw1/ovidweb.cgi#121%23121http://gateway.ut.ovid.com/gw1/ovidweb.cgi#TT1%23TT1http://gateway.ut.ovid.com/gw1/ovidweb.cgi#91%2391http://gateway.ut.ovid.com/gw1/ovidweb.cgi#90%2390http://gateway.ut.ovid.com/gw1/ovidweb.cgi#TT4%23TT4http://gateway.ut.ovid.com/gw1/ovidweb.cgi#91%2391http://gateway.ut.ovid.com/gw1/ovidweb.cgi#toc%23tochttp://gateway.ut.ovid.com/gw1/ovidweb.cgi#123%23123http://gateway.ut.ovid.com/gw1/ovidweb.cgi#121%23121http://gateway.ut.ovid.com/gw1/ovidweb.cgi#TT1%23TT1http://gateway.ut.ovid.com/gw1/ovidweb.cgi#91%2391http://gateway.ut.ovid.com/gw1/ovidweb.cgi#90%2390http://gateway.ut.ovid.com/gw1/ovidweb.cgi#TT4%23TT4http://gateway.ut.ovid.com/gw1/ovidweb.cgi#91%2391


11/18

8$ble 4' ,ot$..ium Suppleme!t.

,ot$..ium .$lt. i!clue pot$..ium clorie" pot$..ium po.p$te" $! pot$..ium

bic$rbo!$te' ,ot$..ium po.p$te i. ou! prim$ril% i! oo" $! pot$..ium bic$rbo!$te

i. t%pic$ll% recomme!e we! pot$..ium epletio! occur. i! te .etti! o met$bolic

$cio.i. (p FJ'4)' >! $ll oter .etti!." pot$..ium clorie .oul be u.e bec$u.e o

it. u!iue eective!e.. $$i!.t te mo.t commo! c$u.e. o pot$..ium epletio!'

oreover" %pocloremi$ m$% evelop i citr$te" bic$rbo!$te" luco!$te" or $!oter

$l5$li!iBi! .$lt i. $mi!i.tere" p$rticul$rl% i! p$tie!t. $eri! to iet. t$t re.trict te

i!t$5e o clorie' ,ot$..ium clorie i. $v$il$ble i! eiter liui or t$blet ormul$tio!.(8$ble 4)" 2 $! $ll pot$..ium ormul$tio!. $re re$il% $b.orbe' Altou liui orm.

m$% be le.. e@pe!.ive" te% $ve $ .tro!" u!ple$.$!t t$.te $! ote! $re !ot well

toler$te'

C!MPLIANC& I""$&" AN% P!A""I$M R&PLAC&M&N(&RAP)

A. wit m$!% lo!-term ter$pie." compli$!ce c$! be $ c$lle!e wit pot$..ium

.uppleme!t$tio!' Speciic c$r$cteri.tic. o $ meic$tio!" .uc $. $ppe$r$!ce" color"

t$.te" .iBe" e$.e o .w$llowi!" $! co.t c$! $ll i!lue!ce p$tie!t compli$!ce' 4


12/18

Si!ce pot$..ium .uppleme!t. $re t%pic$ll% i!ic$te or lo!-term u.e" it i. import$!t to

optimiBe p$tie!t $ere!ce'P 4<

Reporte $ver.e eect. o pot$..ium .uppleme!t. $ect prim$ril% te $.troi!te.ti!$l

tr$ct" $! te% i!clue !$u.e$" vomiti!" i$rre$" l$tule!ce" $! $bomi!$l p$i! or

i.comort' lcer$tio!. o te .m$ll bowel $ve bee! reporte $ter te $mi!i.tr$tio!o e!teric-co$te pot$..ium clorie t$blet.' A ew c$.e. o .m$ll bowel ulcer$tio!"

.tricture" $! peror$tio! $ve bee! $..oci$te wit w$@-m$tri@ ormul$tio!.' 4J

Altou .low-rele$.e t$blet. $ve bee! $..oci$te wit $.troi!te.ti!$l tr$ct

ulcer$tio!. $! bleei!" te ri.5 o te.e complic$tio!. i. low $! .eem. to be lowe.t

wit te u.e o microe!c$p.ul$te prep$r$tio!.' 2

P!A""I$M R&PL&I!N AN% (& R!L& !# MAGN&"I$M

$!e.ium i. $! import$!t co$ctor or pot$..ium upt$5e $! or te m$i!te!$!ce o

i!tr$cellul$r pot$..ium level.' Rece!t .tuie. u.i! cellul$r moel. co!irm te critic$l

role o m$!e.ium i! m$i!t$i!i! i!tr$cellul$r pot$..ium $! i!ic$te t$t te

mec$!i.m. $re multi$ctori$l' 4= $! $! colle$ue. 4= emo!.tr$te t$t

[email protected]! m$!e.ium $! pot$..ium epletio! coul le$ to rer$ctor% pot$..ium

repletio!" wic i. te i!$bilit% to replete pot$..ium i! te pre.e!ce o u!reco!iBe $!

co!ti!ui! m$!e.ium eicie!c%'

$!% p$tie!t. wit pot$..ium epletio! m$% $l.o $ve m$!e.ium eicie!c%' >!

p$rticul$r" loop iuretic. (e" uro.emie) prouce .ub.t$!ti$l .erum $! i!tr$cellul$r

pot$..ium $! m$!e.ium lo..' io@i! $cceler$te. te e@cretio! o m$!e.ium b%

reuci! it. re$b.orptio! $t te re!$l tubule.' 8e role o m$!e.ium i! m$i!t$i!i!

i!tr$cellul$r pot$..ium i. p$rticul$rl% import$!t i! c$ri$c m%oc%te. bec$u.e ite.e!.itiBe. tem to te c$lcium-i!uce $rr%tmoe!ic $ctio!. o c$ri$c l%co.ie.'

Routi!e etermi!$tio! o .erum m$!e.ium level. .oul be co!.iere we!ever te

me$.ureme!t. o .erum electrol%te. $re !ece..$r% i! $ p$tie!t' $! et $l 4=

recomme! co!.ieri! te repletio! o bot m$!e.ium $! pot$..ium or p$tie!t.

wit %po5$lemi$' iet$r% .ource. o m$!e.ium i!clue wole-r$i! cere$l." pe$."

be$!." !ut." coco$" .e$oo" $! $r5 ree! veet$ble.'

C!N"&N"$" G$I%&LIN&" #!R (& $"& !# P!A""I$MR&PLAC&M&N IN CLINICAL PRACIC&

/ow .erum pot$..ium co!ce!tr$tio! i. per$p. te mo.t commo! electrol%te

$b!orm$lit% e!cou!tere i! cli!ic$l pr$ctice' Str$teie. $ime $t $cievi! $!

m$i!t$i!i! !ormo5$lemi$ mu.t t$5e i!to $ccou!t .uc $ctor. $. (1) b$.eli!e

pot$..ium v$lue." (2) te pre.e!ce o u!erl%i! meic$l co!itio!. (e" C)" (3) te

u.e o meic$tio!. t$t $lter pot$..ium level. (e" !o!Mpot$..ium-.p$ri! iuretic.) or

t$t le$ to $rr%tmi$. i! te pre.e!ce o %po5$lemi$ (e" c$ri$c l%co.ie.)" (4)

p$tie!t v$ri$ble. .uc $. iet $! .$lt i!t$5e" $! (


13/18

pr$ctice. or te u.e o pot$..ium' 8e uieli!e. were evelope $t $ 199= meeti! o

te &$tio!$l Cou!cil o! ,ot$..ium i! Cli!ic$l ,r$ctice' >t i. cle$r t$t co!trolle cli!ic$l

.tuie. $re !ece..$r% to etermi!e te .peciic recomme!$tio!.'

General Guidelines

1' Dietary cons)mption o* potassi)m+rich *oods sho)ld be s)pplemented ,ith potassi)m

replacement therapy. te!" i!cre$.i! iet$r% pot$..ium i!t$5e i. !ot completel%

eective i! repl$ci! te pot$..ium lo.. $..oci$te wit clorie epletio! (e" t$t

wic occur. i! iuretic ter$p%" vomiti!" or !$.o$.tric r$i!$e) bec$u.e iet$r%

pot$..ium i. $lmo.t e!tirel% couple wit po.p$te" r$ter t$! wit clorie' >!

$itio!" te co!.umptio! o pot$..ium-ric oo. i! $mou!t. t$t $re .uicie!t to

i!cre$.e te level o .erum pot$..ium level to $ccept$ble co!ce!tr$tio!. m$% be co.tl%"

$! it m$% le$ to weit $i!'

2' (otassi)m replacement is recommended *or individ)als ,ho are sensitive to sodi)m

or ,ho are )nable or )n,illing to red)ce salt inta-e it is especially e**ective inred)cing blood press)re in s)ch persons. A i-.oium iet ote! re.ult. i! [email protected]

uri!$r% pot$..ium lo..'

3' (otassi)m replacement is recommended *or individ)als ,ho are s)bect to na)sea!

vomiting! diarrhea! b)limia! or di)retic/laative ab)se. ,ot$..ium clorie $. bee!

.ow! to be te mo.t eective me$!. o repl$ci! $cute pot$..ium lo..'

4' (otassi)m s)pplements are best administered orally in a moderate dosage over a

period o* days to ,ee-s to achieve the *)ll repletion o* potassi)m.


14/18

be re$re $. i!co!.eue!ti$l' iet$r% co!.umptio! o pot$..ium-ric oo. $!

pot$..ium .uppleme!t$tio! .oul be i!.titute $. !ece..$r%'

Patients With CHF

(otassi)m replacement sho)ld be ro)tinely considered in patients ,ith C6F! even i* theinitial potassi)m determination appears to be normal 3eg! .0 mmol/&5. 8e m$Eorit% o

p$tie!t. wit C $re $t i!cre$.e ri.5 or %po5$lemi$' >! p$tie!t. wit C or

m%oc$ri$l i.cemi$" mil-to-moer$te %po5$lemi$ c$! i!cre$.e te ri.5 o c$ri$c

$rr%tmi$' >! $itio!" iuretic-i!uce %po5$lemi$ c$! i!cre$.e te ri.5 o iit$li.

i!to@ic$tio! $! lie-tre$te!i! $rr%tmi$.'

>! lit o te $bove i!orm$tio! $! te pote!ti$l or %per5$lemi$ to occur .eco!$r%

to ru ter$p% wit AC7 i!ibitor. or $!iote!.i! >> receptor bloc5er." reul$r

mo!itori! o te .erum pot$..ium level i. e..e!ti$l i! te.e p$tie!t.' At $!% time" .tre..

c$! trier te .ecretio! o $lo.tero!e $! te rele$.e o c$tecol$mi!e i! re.po!.e to

low c$ri$c output" tereb% precipit$ti! $ $ll i! te .erum pot$..ium level'

Patients With Cardiac Arrhythmias

Maintenance o* optimal potassi)m levels 3at least .0 mmol/&5 is critical in these

patients and ro)tine potassi)m monitoring is obligatory. ,$tie!t. wit e$rt i.e$.e $re

ote! .u.ceptible to lie-tre$te!i! ve!tricul$r $rr%tmi$.' >! p$rticul$r" .uc

$rr%tmi$. $re $..oci$te wit e$rt $ilure" let ve!tricul$r %pertrop% (c$r$cteriBe

b% $! $b!orm$l RS comple@)" m%oc$ri$l i.cemi$" $! m%oc$ri$l i!$rctio! (bot

i! te $cute p$.e $! $ter remoeli!)' 8e co$mi!i.tr$tio! o m$!e.ium .oul be

co!.iere to $cilit$te te cellul$r upt$5e o pot$..ium'

Patients Prone to Stroke

%t is pr)dent to maintain optimal potassi)m levels in patients at high ris- *or stro-e

3incl)ding those ,ith a history o* atherosclerotic or hemorrhagic cerebral vasc)lar

accidents5. Altou te eective!e.. o pot$..ium .uppleme!t$tio! i! reuci! te

i!cie!ce o .tro5e i! um$!. $. !ot bee! emo!.tr$te i! r$!omiBe co!trolle

tri$l." pro.pective .tuie. .ue.t t$t te i!cie!ce o $t$l $! !o!$t$l .tro5e

correl$te. i!ver.el% wit iet$r% pot$..ium i!t$5e' >! $itio!" te $..oci$tio! o .tro5e

wit %perte!.io! i. well 5!ow!'

Patients With Diabetes Mellitus

(otassi)m levels sho)ld be closely monitored in patients ,ith diabetes mellit)s and

potassi)m replacement therapy sho)ld be administered ,hen appropriate. $t$

u!er.core te $ver.e eect. o luco.e $! i!.uli! o! pot$..ium level. $! te i

i!cie!ce o c$riov$.cul$r $! re!$l complic$tio!. i! p$tie!t. wit i$bete. mellitu.'

8e.e $ctor. $re .peciic to p$tie!t. wit t%pe 2 i$bete. wo $ve poorl% co!trolle

.erum luco.e level.'

Patients With Renal Impairment

http://gateway.ut.ovid.com/gw1/ovidweb.cgi#toc%23tochttp://gateway.ut.ovid.com/gw1/ovidweb.cgi#toc%23tochttp://gateway.ut.ovid.com/gw1/ovidweb.cgi#toc%23tochttp://gateway.ut.ovid.com/gw1/ovidweb.cgi#toc%23tochttp://gateway.ut.ovid.com/gw1/ovidweb.cgi#toc%23toc


15/18

Data s)ggest a lin- bet,een potassi)m levels and lesions o* the -idneys in patients ,ith

renal disease or diabetes. A!im$l .tuie. $ve emo!.tr$te t$t pot$..ium m$% oer $

protective eect o! te re!$l $rteriole.' 8e cli!ic$l implic$tio!. o te.e i!i!. $re

!ot %et cle$r'

Accepte or public$tio! ebru$r% 2=" 2000'

8i. $rticle i. b$.e o! $ .%mpo.ium .upporte b% $ r$!t rom +e% ,$rm$ceutic$l."

+e!ilwort" '

8e &$tio!$l Cou!cil o! ,ot$..ium i! Cli!ic$l ,r$ctice p$rticip$!t. i!clue; #$% &'

Co!" "ep$rtme!t o eici!e" !iver.it% o i!!e.ot$ eic$l Scool"

i!!e$poli.* ,eter R' +owe%" " ep$rtme!t o C$riolo%" /$!5e!$u o.pit$l $!

eic$l Re.e$rc Ce!ter" %!!ewoo" ,$" ep$rtme!t o eici!e" #eer.o! eic$l

Collee" ,il$elpi$" ,$* H$rr% #' $ter.o!" " ep$rtme!t o eici!e" !iver.it%

o i$mi" i$mi" l$* /' ic$el ,ri.$!t" " ep$rtme!t o eici!e" irector o

C$riolo% ellow.ip 8r$i!i!" eic$l Collee o :eori$" Auu.t$* 7liE$ S$u!er."" ep$rtme!t o eici!e" %perte!.io! ivi.io!" !iver.it% o $r%l$! Scool

o eici!e" H$ltimore* orot% /' Smit" ,$rm" ,re.ie!t" Co!.umer e$lt

>!orm$tio! Corpor$tio!" c/e$!" V$" ep$rtme!t o Commu!it% $! $mil%

eici!e" :eoretow! !iver.it% Scool o eici!e" $.i!to!" C* /oui. 8obi$!"

" ep$rtme!t o eici!e" ivi.io! o %perte!.io!" !iver.it% o i!!e.ot$

eic$l Scool" i!!e$poli.* $! ,$ul +' elto!" " 8ul$!e !iver.it% Scool o

,ublic e$lt $! 8ropic$l eici!e" &ew rle$!." /$'

References

1' $!$l A+' %po5$lemi$ $! %per5$lemi$' e Cli! &ort Am' 199J*=1;611-639' Bibliographic Links [Co!te@t /i!5]

2' :e!!$ri #' %po5$lemi$' & 7!l # e' 199=*339;4


16/18

10' >.imit.u 8" 8obi$! /" Suimoto +" 7ver.o! 8' i pot$..ium iet. reuce v$.cul$r $! pl$.m$ lipi

pero@ie. i! .tro5e-pro!e .po!t$!eou.l% %perte!.ive r$t.' Cli! 7@p %perte!.' 1996*1=;6.imit.u 8" 8obi$! /" Suimoto +" /$!e #' i pot$..ium iet. reuce m$crop$e $ere!ce to te

v$.cul$r w$ll i! .tro5e-pro!e .po!t$!eou.l% %perte!.ive r$t.' # V$.c Re.' 199.imit.u 8" 8obi$! /" e$r$ ?" Suimoto +" /$!e #' 7ect o i pot$..ium iet. o! te v$.cul$r $!

re!$l pro.t$l$!i! .%.tem i! .tro5e-pro!e .po!t$!eou.l% %perte!.ive r$t.' ,ro.t$l$!i!. /eu5ot 7..e!t $tt%Aci.' 199!ter! e'

1991*11&87RSA/8; $! i!ter!$tio!$l .tu% o eletrol%te e@cretio! $!

bloo pre..ure; re.ult. or 24-our uri!$r% .oium $! pot$..ium e@cretio!' H#' 19==*29J;319-32=' [Co!te@t/i!5]

20' :eleiE!.e #" ittem$! #C" e! HreeiEe! #" et $l' iet$r% electrol%te i!t$5e $! bloo pre..ure i! oler

.ubEect.; 8e Rotter$m Stu%' # %perte!.' 1996*14;J3J-J41' Bibliographic Links [Co!te@t /i!5]

21' elto! ,+" e #" Cutler #A" et $l' 7ect. o or$l pot$..ium o! bloo pre..ure; met$-$!$l%.i. o

r$!omiBe co!trolle cli!ic$l tri$l.' #AA' 199J*2JJ;1624-1632' [Co!te@t /i!5]

22' 8e Si@t Report o te #oi!t &$tio!$l Committee o! ,reve!tio!" etectio!" 7v$lu$tio!" $! 8re$tme!t o

i Hloo ,re..ure' Arc >!ter! e' 199J*1!ter! e' 19=3*9=;JJ0-JJ2'Bibliographic Links [Co!te@t /i!5]

24' $t.o! R/" /$!or :" Aber!et% #" H$r!e. 8?" $t.o! #' ri!$r% electrol%te." bo% weit" $!

bloo pre..ure; poole cro..-.ectio!$l re.ult. $mo! our roup. o $ole.ce!t em$le.' %perte!.io!'

19=0*2(4 ,t 2);93-9=' [Co!te@t /i!5]

2


17/18

2J' &ol$! #" H$ti! ," A!rew. R" et $l' ,ro.pective .tu% o e$rt r$te v$ri$bilit% $! mort$lit% i! cro!ic

e$rt $ilure; re.ult. o te !ite +i!om e$rt $ilure 7v$lu$tio! $! A..e..me!t o Ri.5 8ri$l (+-

e$rt)' Circul$tio!' 199=*9=;1!-o.pit$l ve!tricul$r ibrill$tio! $! it. rel$tio! to .erum pot$..ium' Act$ e Sc$! Suppl'19=1*64J(.uppl);109-116' Bibliographic Links [Co!te@t /i!5]

3=' :r$$m ?" Smit #/" Houvet AA' $t $ppe!. to t$blet. $! c$p.ule. i! te .tom$c e!o.copiccomp$ri.o! o i.i!ter$tio! $! i.per.io! c$r$cteri.tic. o two microe!c$p.ul$te pot$..ium ormul$tio!.' #

,$rm Sci' 1990*J9;420-424' Bibliographic Links

39' c$o! :" R%$! #R" A5$m$r +" 7rt$! A' pper $.troi!te.ti!$l le.io!. $ter pot$..ium clorie

.uppleme!t.; $ co!trolle cli!ic$l tri$l' /$!cet' 19=2*2;10!ter! e' 19=J*14J;9


18/18

4!; Coe! S#" e' $e, Directions in (atient Compliance. /e@i!to!" $..; /e@i!to! Hoo5.* 19J9;16'[Co!te@t /i!5]

4J' :r$$m ?' 7ective!e.. $! toler$!ce o P.oliP v.' PliuiP pot$..ium repl$ceme!t ter$p%' >!;

C$mero! #S" :lu..oc5 R#" elto! A" e.' 8idney Disease. &ew ?or5" &?; $rcel e55er >!c* 19=6*6;c$p

36' [Co!te@t /i!5]

4=' $! R" $! " R%$! ,' Rer$ctor% pot$..ium repletio!; $ co!.eue!ce o m$!e.ium eicie!c%'

Arc >!ter! e' 1992*1

New Guidelines for Potassium Replacement in Clinical Practice

Documents

Transcript of New Guidelines for Potassium Replacement in Clinical Practice