Episode 47. I Plead the Fifth! 5 vs 10 units of Insulin for Hyperkalemia

Image of Insulin dosing for hyperkalemia

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  • Insulin with dextrose is an effective method to lower potassium levels quickly in acute hyperkalemia
  • Literature shows ranges of potassium reduction by 0.5-1.0 mEq after administration of a single dose.
  • Patients with renal insufficiency and end-stage renal disease (ESRD) have a higher incidence of hypoglycemia after treatment with insulin for hyperkalemia due to:
    • Reduced insulin clearance (prolonged insulin action)
    • Reduced hepatic glucose production
    • Reduced renal gluconeogenesis

The appropriate dose of insulin to minimize hypoglycemic events when using for the treatment of hyperkalemia in patients with renal insufficiency is still debated.


Regular Insulin

MechanismCause an intracellular shift of potassium via exchange of sodium ions via the Na+/K+ ATPase pump
Dose5-10 units Doses of 0.1 units/kg (max 10 units) have also been considered
AdministrationIV push
PK/PDOnset: 15-30 minutes for initial potassium lowering effects
Duration: 4-6 hours, prolonged duration in ESRD
Adverse EffectsHypoglycemia, hypokalemia, hypersensitivity
CompatibilityCan dilute in normal saline to increase volume for ease of administration
PearlsMust be given with dextrose (25g IV) to prevent hypoglycemia
—–Some patients require repeated dextrose; rare exceptions for those already extremely hyperglycemic

The most commonly used product is regular human insulin given IV to ensure the fast onset of potassium lowering effects and prevent variable absorption
Pharmacology Chart for insulin in hyperkalemia
Pharm So hard picture describing the dosing of insulin in hyperkalemia
insulin Mechanism of action for hyperkalemia
Mechanism of action for insulin in hyperkalemia

Review of Evidence

Author, Year Design (Sample Size) Intervention & Comparison Outcomes
Moussavi et al., 2021Meta-analysis
(n = 3437)
10 units vs <10 units IV regular insulin• <10 units IV regular insulin had lower pooled odds of hypoglycemia odds ratio [OR] 0.55 and severe hypoglycemia OR 0.41

• No difference in potassium reduction was detected mean difference -0.02 mmol/L
Verdier et al., 2021Single-center, retrospective (n =174)5 units vs 10 units IV regular insulin in ICU patients• Hypoglycemia was more frequent with 10 units vs 5 units of IV insulin (19.5 vs 9.2%, p=0.052)

• No difference in rates of severe hypoglycemia or change in serum potassium
Review of Moussavi et al Meta-Analysis and Verdier et al study

Moussavi et al conducted a Meta-analysis (n = 3437) that looked at 10 units vs <10 units IV regular insulin. They found that <10 units IV regular insulin had lower pooled odds of hypoglycemia odds ratio [OR] 0.55 and severe hypoglycemia OR 0.41


  • Hypoglycemia risk seems to be elevated in those patients with renal insufficiency, especially those who are insulin-naive
  • Consideration should be made to lower the initial dose of IV insulin for patients with AKI or CKD
Episode 47. I Plead the Fifth. 5 vs 10 units of Insulin for the Management of Hyperkalemia in Patients with Renal Dysfunction

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Jimmy L. Pruitt III, PharmD, BCPS, BCCCP

The Pharm So Hard Podcast is a show focused primarily on emergency medicine and hospital pharmacy related topics. To empower healthcare providers with the knowledge and skills they need to provide evidence-based, safe care for critically ill patients.

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