Nebulized Albuterol for the Treatment of Hyperkalemia Department

Nebulized Albuterol for the Treatment of Hyperkalemia Department of Emergency Medicine University of Pennsylvania Health System Vincent Retirado MD April 13, 2004

Clinical Studies l l l Montoliu J, et al. Treatment of Hyperkalemia in Renal Failure with Salbutamol Inhalation. J Intern Med. 228: 35 -37 1990. Allon M, et al. Nebulized Albuterol for Acute Hyperkalemia in Patients on Hemodialysis. Ann Intern Med 110: 426 -429 1989. Allon M, et al. Albuterol and Insulin for Treatment of Hyperkalemia in Hemodialysis Patients. Kidney Int. 38: 869 -872 1990.

Montoliu et al. A prospective observational study from the University of Barcelona Medical Center l Inclusion criteria: non-diabetic, advanced renal failure (GFR < 5 ml/min) on chronic hospital hemodialysis, hyperkalemic (K+ > 6) and able to cooperate with procedure of salbutamol inhalation. l

Montoliu et al. 10 patients enrolled – all completed the study l 2 women, 8 men l 15 mg of nebulized albuterol diluted in 10 ml of normal saline was administered over 30 minutes. l K+ concentration, blood pressure and heart rate were measured prior to administration of albuterol, 30, 60, 180 and 360 minutes after termination l Side effect were recorded l

Montoliu et al. l Results:

Montoliu et al. Serum potassium levels decreased significantly from pretreatment value of 6. 5 + 0. 6 mmol/L to 5. 6 + 0. 6 mmol/L after 30 minutes and this level maintained for 3 hours. l Serum potassium levels were still decreased at 6 hours at 6 + 0. 7 mmol/L. l Side effects included a modest increase in heart rate (max 103 + 8). l

Allon et al. , 1989 l l A prospective double blind and placebo-controlled study from the outpatient hemodialysis clinic at the VA Medical Center, Oklahoma City. Inclusion criteria: Pt’s with ESRD on maintenance hemodialysis for at least 3 months, receiving dialysis in 3 to 4 hour sessions three times weekly, chronic hyperkalemia with K+ concentrations consistently > 5 mmol/L, no current use of B-blockers. 10 patients enrolled – 1 patient withdrew from the study and another patient died prior to completion of study. Age ranged from 39 to 68 yoa (mean 53 + 11)

Allon et al. , 1989 l l l Patients received a nebulized preparation of either albuterol (10 or 20 mg) in saline or normal saline alone (placebo). Preparation was inhaled for 10 minute period. Patients were studied on 3 different days separated by each other by 1 week. Patient or treating nurse were unaware of the identity of the preparation. K+ concentration, blood pressure and heart rate were measured prior to administration of albuterol and 30 minute intervals for 2 hours after termination of treatment. Patients questioned for symptoms including tremor, palpitations or sweating.

Allon et al. , 1989 l Results:

Allon et al. , 1989 l l l Patients had a significant decrease in plasma potassium concentrations with administration of 10 and 20 mg doses of nebulized albuterol with maximal decrease of 0. 62 + 0. 09 and 0. 98 + 0. 14 mmol/L respectively. Nebulized saline did not produce a significant change in potassium concentrations. Patients did not develop symptoms or significant changes in blood pressure or heart rate with treatment.

Allon et al. , 1990 l l A prospective observational study from the outpatient hemodialysis clinic at the VA Medical Center, Oklahoma City. Inclusion criteria: Pt’s with ESRD on maintenance hemodialysis for at least 3 months, receiving dialysis in 3 to 4 hour sessions three times weekly, chronic hyperkalemia with K+ concentrations consistently > 5 mmol/L, no current use of B-blockers and non-diabetic. 12 patients enrolled - one patient withdrew from study and another transferred to peritoneal dialysis. Age range 34 and 72 yoa (mean, 56. 6 + 3. 6 years)

Allon et al. , 1990 l l Patients received one of three treatments: (a) 10 units regular insulin IV followed by glucose D 50 IV, (b) nebulized preparation of albuterol 20 mg in saline or (c) a combined regimen. Patients were studied on 3 different days separated by each other by 1 week. K+ concentration, blood pressure and heart rate were measured prior to administration of treatment and 15 minute intervals for 1 hour after termination of treatment. Patients questioned for symptoms including tremor, palpitations or sweating.

Allon et al. , 1990 l l l There was a similar decrease in plasma potassium following either insulin with glucose (0. 65 + 0. 09 mmol/L) or albuterol (0. 66 + 0. 12 mmol/L). There was a substantial greater decrease with combined regimen of insulin with glucose and albuterol (1. 21 + 0. 19 mmol/L). Treatment with insulin or albuterol produced trivial increase in heart rate, whereas the combined regimen was associated with a significant rise in heart rate (15. 1 + 6. 0 beats/min)

Allon et al. , 1990 l Results:

HUPism l l Nebulized albuterol is effective in the temporary treatment of hyperkalemia in adult patients with chronic renal failure. Effective Dose – 10 to 20 mg nebulized (adult) K+ concentrations begin to fall within 30 minutes of administration, are maintained at a constant reduced concentration for approximately 1 to 2 hours and are still depressed at 6 hours. Nebulized albuterol has an additive effect on lowering K+ levels when used with insulin/glucose treatment.