In Reference to: “Preventing Hypoglycemia Following Treatment of Hyperkalemia in Hospitalized Patients”

Abstract

B oughton et al. 1 reported a high incidence of hypoglycemia resulting from glucose-with-insulin (GwI) infusion used to treat acute hyperkalemia. This has been reported by other investigators-particularly in subjects without preexisting diabetes 2 and resonates with the experiences of clinicians practicing in Internal Medicine or Diabetes.The authors suggested that patients at risk of hypoglycemia be identified and offered a regimen containing less insulin. However, for subjects without preexisting diagnosis and not at high risk of diabetes, we question the physiological logic and the safety basis for administering insulin.Infusion of glucose only (GO) to subjects with intact pancreatic function and insulin sensitivity stimulates endogenous insulin secretion in a dose-dependent manner, resulting in a reduction in extracellular fluid potassium with no risk of hypoglycemia. 3,4 It is unclear why GwI historically entered mainstream practice rather than GO, but the rationale may have been based on the potential risks of paradoxical hyperglycemia-mediated hyperkalemia (HMK) being induced by GO. In practice, HMK was only observed in subjects with diabetes. 5As there is an ongoing need to reduce the impact of iatrogenic hypoglycemia, revisiting of the prematurely abandoned GO regimen in hyperkalemia management is warranted. Such approach may offer a safe and physiological alternative to GwI in nondiabetic patients with hyperkalemia.We advocate that GO be prospectively evaluated against GwI for the treatment of hyperkalemia in subjects without diabetes, against the endpoints being noninferiority in respect of efficacy and maintenance of euglycemia in respect of safety.Disclosures: Nothing to declare References 1. Boughton CK, Dixon D, Goble E, et al. Preventing hypoglycemia following treatment of hyperkalemia in hospitalized patients. in the treatment of hyperkalemia with insulin in patients with end-stage renal disease. Clin Kidney J. 2014;7(3):248-250. doi: 10.1093/ckj/sfu026. 3. Chothia MY, Halperin ML, Rensburg MA, Hassan MS, Davids MR. Bolus administration of intravenous glucose in the treatment of hyperkalemia: a randomized controlled trial. Effects of glucose administration on the potassium and inorganic phosphate content of the blood serum and the electrocardiogram in normal individuals and in non-diabetic patients.

Iatrogenic hypoglycaemia following glucose‐insulin infusions for the treatment of hyperkalaemia

“…Several suggestions have been made to reduce risk of hypoglycaemia from GwI infusions, 9,17 including administering a lower dose of insulin, preloading with additional glucose or administering a higher overall glucose load.…”

“…Previous publications have highlighted the risk of iatrogenic hypoglycaemia (capillary blood glucose ≤ 3.9 mmol/L) following hyperkalaemia treatment with GwI infusions; the reported incidence ranges from 6% to 75% 5‐9 . Patients with hyperkalaemia may have additional risk factors for hypoglycaemia, such as end‐stage renal disease, or diabetes treated with insulin or insulin secretagogue therapy.…”

“…Previous publications have highlighted the risk of iatrogenic hypoglycaemia (capillary blood glucose ≤ 3.9 mmol/L) following hyperkalaemia treatment with GwI infusions; the reported incidence ranges from 6% to 75%. [5][6][7][8][9] Patients with hyperkalaemia may have additional risk factors for hypoglycaemia, such as end-stage renal disease, or diabetes treated with insulin or insulin secretagogue therapy. Hypoglycaemia has potentially life-threatening consequences, including precipitation of acute cardiovascular events and cardiac arrhythmia, and may cause life-changing generalized brain injury in the long term.…”

In Response to “In Reference to: ‘Preventing Hypoglycemia Following Treatment of Hyperkalemia in Hospitalized Patients‘”

“…e appreciate the comments and interest of Al-Sharefi and colleagues who highlight the use of glucose-only infusion in the management of hyperkalemia. 1 The incidence of hypoglycemia following hyperkalemia treatment with insulin/dextrose is high and measures to reduce this should be pursued. 2 However, evidence of the efficacy of glucose-only infusions on lowering potassium in heterogeneous inpatient populations is lacking.…”