Drug-Induced Hyperkalemia:Case Presentation and Discussion

James D. Coyle, Pharm.D.Winter, 2002

Case Series – Drug-Induced Hyperkalemia (1)

• Series of 5 patients (3 M, 2 F), 53–81 yoa

• All taking an ACE-inhibitor, to which amiloride HCl/hydrochlorothiazide was added

• Ann Emerg Med 1997;30:612-615.

Case Series – Drug-Induced Hyperkalemia (2)

Case No.

Age/Sex

PMH Symptoms

1 53 M DM, HTN ½ day weakness, numbness in limbs; abrupt onset VF in ED

2 81 M DM, HTN, gouty arthritis, CKD

Dizziness, nausea, vomiting, slow pulse X several hours (HR 35)

3 70 F DM, HTN, CHF, CKD

Progressive disorientation, confusion over 3 days; slow, irregular pulse (HR 55)

4 66 F DM, HTN, gouty arthritis, CKD

Generalized weakness X 3 days, abdominal pain; collapsed suddenly in ED

5 55 M DM, HTN, CHF Generalized weakness X 3 days

Case Series – Drug-Induced Hyperkalemia (3)

Case No.

Medications Na Kbefore

Kafter

Cr

1 Enalapril (20 mg BID x 2 mos);Amil/HCTZ (1 tab QD x 16 days)

123 3.3 9.4 1.6

2 Enalapril (10 mg QD x 7 wks, then 20 mg x 8 days); amil/HCTZ (1 tab QD x 8 days)

133 4.1 9.9 2.7

3 Enalapril (5 mg QD x 1 mo); amil/HCTZ (1 tab QD x 15 days)

131 4.0 10.4 2.5

4 Enalapril (20 mg QD x 1 mo); amil/HCTZ (1/2 tab QD x 15 days)

129 6.7 11 2.4

5 Captopril (12.5 mg TID, increased to 25 mg TID x 8 days); amil/HCTZ (1 tab QD x 8 days)

124 2.0 6.8 1.2

Case Series – Drug-Induced Hyperkalemia (4)

Case No.

Treatment Outcome

1 CaCl2, NaHCO3, dextrose with insulin Death

2 Discontinued enalapril and amil/HCTZ Recovery

3 Emergency hemodialysis Recovery

4 External pacemaker, aggressive resuscitation

Death

5 Discontinued captopril and amil/HCTZ Recovery

Case Series – Drug-Induced Hyperkalemia (5)

Case No.

ACE-I +Amil/HCTZ

Cr >2.0

MetabolicAcidosis

NSAIDs Rhabdo-myolysis

1 + - + - -

2 + + ND + -

3 + + + - -

4 + + - + -

5 + - - - -

Summary

• Common characteristics and tx of patients with severe, symptomatic hyperkalemia

• Absence of absolute relationship between serum K and symptom severity

• Potential hazards of using two (or more) drugs that can increase K concentrations

• Characteristics of patients requiring particularly careful monitoring