Challenges of pharmacological Treatment and Management of Hyperkalemia in Patients on RAAS Inhibitors – ESC Congress 2025 Highlights
Challenges of pharmacological Treatment and Management of Hyperkalemia in Patients on RAAS Inhibitors – ESC Congress 2025 Highlights
1. Pharmacological Treatment of Hyperkalemia
• ESC HF Guidelines: Potassium-lowering treatment with potassium binders should be initiated if serum potassium exceeds 5.0 mmol/L. RAASi therapy should only be reduced or stopped if potassium exceeds 6.5 mmol/L.
• ACC HF Guidelines: Hyperkalemia is defined at a threshold of ≥5.5 mmol/L.
• KDIGO Guidelines(The term KDIGO stands for Kidney Disease Improving Global Outcomes. It is an international organization focused on improving outcomes for patients with kidney disease through evidence-based guidelines):
RAASi should not be discontinued unless hyperkalemia management strategies fail to normalize potassium levels.
• Newer potassium binders like patiromer and SZC are effective for managing hyperkalemia while maintaining RAASi therapy.
2. Potassium Binder Profiles
• Older Potassium Binders (SPS, CPS) cause gastrointestinal side effects (e.g., constipation, nausea) and carry risks like ulcers and ischemia.
• Patiromer: Exchanges potassium for calcium, making it safer for patients with conditions like hypertension, CKD, or HF.
• SZC: Selectively binds potassium and has a rapid onset, making it ideal for quick potassium reduction.
3. Recommendations for Hyperkalemia Management
• Hyperkalemia is often asymptomatic and should be detected early through regular monitoring, particularly in high-risk patients.
• Potassium binders should be initiated when potassium reaches ≥5.5 mmol/L, confirmed by two tests.
• Treatment should aim to normalize potassium levels (4.0–4.9 mmol/L), as this range is associated with improved clinical outcomes.
• ESC Recommendations: Hyperkalemia should be managed before reducing RAASi doses.
• ACC Recommendations: If potassium cannot be maintained below 5.5 mmol/L, MRAs should be discontinued.
4. Consequences of Hyperkalemia
• Hyperkalemia can lead to fatal cardiac arrhythmias and significantly increased hospitalization rates.
5. Role of Potassium Binders
• Newer potassium binders, like patiromer and SZC, play a crucial role in managing hyperkalemia, allowing the continued use of RAASi therapy without compromising safety.
6. Emergency intervention is necessary for potassium levels exceeding 6.5 mmol/L.
7. Access to New Potassium Binders
• Although patiromer and SZC are highly beneficial, their cost or availability may limit access for some patients, presenting a challenge to effective hyperkalemia management.
This presentation was delivered during the ESC Congress 2025, focusing on the latest advancements and guidelines for the pharmacological treatment and management of hyperkalemia in patients receiving RAAS inhibitors.
