Narrator - Dr. Abel 00:00 Welcome to HelixTalk, an educational podcast for healthcare students and providers, covering real life clinical pearls, professional pharmacy topics and drug therapy discussions. This podcast is Narrator - ? 00:12 provided by pharmacists and faculty members at Rosalind Franklin University, College of Pharmacy. Narrator - Dr. Abel 00:17 This podcast contains general information for educational purposes only. This is not professional advice, and should not be used in lieu of obtaining advice from a qualified health care provider. Narrator - ? 00:27 And now on to the show. Speaker 1 00:31 Welcome to HelixTalk episode 157 I'm your co host, Dr. Kane, and I'm Dr. Patel, and the title of today's episode is "Everything Will Be A-OK: Potassium formulations and dosing for hypokalemia." This is actually a listener requested topic, Dr. Patel. So the listener wanted to know more about potassium supplementation in terms of what products are available and how you dose it for hypokalemia or a low potassium patient. So we've kind of taken that and run with it a little bit today, in terms of, how do you know a patient has low potassium? What do you do about it? Then also, on the inpatient side, we're gonna talk a little bit about IV fluids and how you discern which ones have potassium and which ones don't, and how it's given to your patients as well. Great. Dr. Khyati Patel 01:14 It looks like we have a good mix of both outpatient and inpatient strategies for hypokalemia. So let's get to it. Speaker 1 01:20 So we'll start with a patient case. So we'll just call this patient George. He's a 60 year old man. He was recently diagnosed with heart failure, with preserved ejection fraction, and for his edema, he was given furosemide, or Lasix, 40 milligrams once daily. So appropriately. So his lab's blood chemistry was checked one week after starting furosemide, and it showed a low potassium value of 3.2 mEq/L. You ask George if he has any symptoms of any kind, and he has no complaints, so he's really an asymptomatic patient when it comes to hypokalemia, really, the question that we're going to answer today is, what if anything should be done for George in the setting of a low potassium with a recently added new medication of furosemide. Dr. Khyati Patel 02:06 And to dive more into the normalcy of potassium, the normal serum potassium is 3.5 to 5 mEq/L. And as we all know it, potassium resides within the cell. So this is an intracellular cation, and so very little is out in the blood, circulating only 2% and so that 2% is your 3.5 to 5 mEq/L range. Speaker 1 02:34 And of course, potassium plays a role in a ton of different cellular functions, like making proteins and cellular metabolism and cell growth and things like that. Usually, when we think about potassium in terms of clinical effects, we're more thinking about how potassium is used to alter the intracellular voltage of primarily cardiac cells, but also muscle contractions and other tissues as well. So very low values of potassium can lead to certain kinds of arrhythmias, for example, or even muscle weakness or tetany and other muscular problems, but that typically only happens when potassium is extremely low, not just a little bit less than 3.5 but we're talking like in the twos, or even less than two. Dr. Khyati Patel 03:16 And so as you said, Dr. Kane, hypokalemia is where we have potassium of less than 3.5 and you know, the 3.5 to five milliequivalent per liter range might be a little bit different based on where you practice. I've seen, you know, 3.3 to 5.3 as a normal range too. But in general, this is what we regard it. And you know, when this case, our patients case, you know, a diuretic like furosemide was started. So a lot of the time, the cause behind hypokalemia is drug induced, for example, diuretics, but it could be from other causes such as severe vomiting and diarrhea. You just basically lose all the GI content. Or maybe patients not consuming, maybe they're malnourished or they're not able to consume foods that contain potassium, so lower intake in general can lead to that as well. Speaker 1 04:08 And we can't talk about hypokalemia without talking about hypomagnesemia. And the reason is that the two are often related, meaning that if you have a low serum magnesium, it often promotes potassium loss in the kidney, which means that by having a low magnesium, it can cause you to have a low potassium, and in those situations, if you don't fix the magnesium, it's actually hard to supplement enough to fix the potassium. So kind of as a clinical Pearl here, and we won't get into magnesium supplementation, but as a clinical Pearl if you have a patient with a low potassium level, especially on the inpatient side, especially if they're getting those loop diuretics and things like that, you want to make sure that you've at least assessed the patient's magnesium level. And if it's very low, you do have to co replete both magnesium and potassium. Otherwise, it's going to be hard to achieve your potassium repletion goals for that patient. Dr. Khyati Patel 04:59 Yep. And so. May have to bring on those mag writers as well. When we talk about hypokalemia treatment, you know, we kind of take a dual approach. Obviously, we want to correct or replete the potassium that's missing by giving a potassium supplementation. And we'll talk about different formulation in just a little bit, and then kind of identify underlying reasons for why the potassium is low? Maybe it's the, you know, dietary changes that had happened. Or maybe there is another reason, like a GI loss or experiencing this, you know, diarrhea or vomiting, that's leading to it too. So we might have to work on correcting the underlying reasons as well, Speaker 1 05:39 and then thinking about, you know, assessing a patient with a low potassium level. You know, one of the first steps is to think about, obviously, a drug induced cause. But aside from that, thinking about, is the patient getting enough potassium in their diet? And Dr. Patel, I'm sure most listeners are going to think about bananas. Everyone goes bananas about potassium, right? Dr. Khyati Patel 05:59 They do. That's the easiest thing that comes to mind, exactly. Speaker 1 06:03 And I think it's worth noting, from kind of a dosing perspective, that there are foods that have enough potassium in them. That one, they kind of make up your daily allowance, or daily amount of potassium. But also, some of these food sources, if a patient has them regularly enough, they actually get you to a pretty appreciable amount of potassium per day. So if a patient, let's say, doesn't tolerate a potassium supplement, maybe they could tolerate the banana a day as an example. So I think it's worth talking about, how much potassium do we have in these products, and how does that compare to where the pharmacologic repletion of an actual like potassium chloride tablet that a patient may take. Dr. Khyati Patel 06:42 Yeah, and while the bananas are regarded as the, you know, the obvious source of potassium and food, you'd be surprised how many different foods, aside from bananas, contain even larger amount of potassium than bananas. And a good example is potato. Let's just take your medium sized potato contains about 14 milli equivalent of potassium. Recently, I found out with a patient situation that watermelon contains a lot of potassium too. So here, you know, nobody sits there and eats an entire watermelon, but let's just say two wedges of watermelon has as good as 16 milli equivalent of potassium. And just Speaker 1 07:20 for context, a typical banana is going to have about 10 mEq of potassium. So these other foods depend on how much you eat. Of them could actually exceed that kind of one banana 10 mEq amount. Other foods could be things like cooked spinach, a cup of that is about 14 mEq. A cup of beets, about 13 mEq. There's other foods as well, right? Dr. Patel, right? Dr. Khyati Patel 07:42 The dried figs, the raisins, you know, even avocados, oranges, they all contain a good amount of potassium. And then there is many more than what we describe. You know, either These were, these were kind of the fruits that are either equivalent or more than the banana that the standard staple food that contains potassium. But then there's lots of fruits, vegetables and even meat, items that you know, somebody will have to consume a little bit more in order to get to, like that 10 milli equivalent standard. Speaker 1 08:16 That's a as a general rule of thumb. There are some of these key foods that based on patient preference, if we're trying to have them supplement their diet with more potassium rich foods, we can probably pick one that will meet their requirements. And most of these foods, for typical serving, they're going to get you around 10 to 15 mEq (milliequivalents), which is actually a pretty appreciable dose. You know, we have a 10 mEq potassium tablet available pharmacologically. So these are kind of on par with what you might expect from a lower dose of a potassium supplement. Dr. Khyati Patel 08:49 And so when we talk about the recommended daily value potassium, it's about 130 milli equivalent. So you got lot of these food choices to make that up. Although the recommended adequate intake is about 90 milli equivalents. So you got to have to eat a lot of these different foods to get to that potassium level that you that you need. And on average, you know, we're going to need about 50–100 mEq per day in order to maintain all the functions that we talked about what potassium helps with, and then, you know, kidneys can help a little bit to balance, either retain or, you know, waste the extra potassium. It's when, when you have additional factors, such as the medications like our loop diuretics or ACE inhibitors or ARBs, that's when kidneys kind of have a hard time keeping that balance of potassium, and that's where you know things can go, either hypo or hyperkalemia. Speaker 1 09:49 So given that humans need about 50 to 100 mEq per day to have a normal potassium, I think that keeping that into context in terms of how we dose is important. And so on that outpatient side, for someone who just chronically needs a little extra potassium, because, let's say that they're on a loop diuretic that makes their kidneys pee out extra potassium they normally would hold on to. For that kind of a patient like George, we might give someone like that somewhere between 20 to 40 mEq per day of extra potassium through supplementation. Typically we don't give more than 20 mEq as a single dose, because it can be pretty irritating to the GI lining. So for that patient that needs extra oftentimes they'll divide up the dose. So if they need 40 mEq, they might take 20 mEq twice a day to get to that 40 mEq per day. Dr. Khyati Patel 10:38 And on the inpatient side, Dr. Kane, you know, you probably can talk a little bit more, but we can. We can situate the potassium dosing based on, you know, how the patient's presenting. So whether it's acute illness, patient has acute kidney failure or not, whether they are on large doses of diuretics that's wasting their potassium, or whether we are starting, or, you know, stopping the ace or the ARB inhibitors, etc. And so unlike the chronic supplementation on the inpatient side, we can design the potassium doses on a daily basis. So you check the potassium and then then you dose accordingly, yeah. Speaker 1 11:17 And it kind of makes sense, because so many things are changing on the inpatient side every single day in terms of meds being added, removed, diet starting, stopping, versus on the outpatient side, patients are more predictable. So as a general rule of thumb, for a patient who needs extra potassium, we'll give 10 mEq of potassium, either IV or orally, and every 10 mEq that we give will increase their serum potassium by about 0.1 so let's say a patient has a potassium level of 3.6 and we want to replete them all the way up to four. So they're 0.4 mEq/L away from our goal, we would give them 40 mEq of potassium to increase them by 0.4; again, for every 10 mEq we give, it increases by 0.1 and usually we won't give more than about 40 in a single sitting before we recheck their potassium. Make sure that we haven't over repeated them. There are some exceptions to that, but generally speaking, we'll recheck them later in the day, at least if we want to give a lot more potassium to them. Dr. Khyati Patel 12:21 And we can get into, you know, calculating the total body deficit. So in general, when potassium is lower than 3.5 our body is considered to be in substantial potassium deficit. So let's say a patient's potassium is the serum potassium level. It's 2.5 you can estimate that the patient will eventually need more than 100 milli equivalents of potassium to replete. Obviously, we're not going to give all this 100 milli equivalent at once, but that's kind of like the overarching goal for repletion. Quote, unquote. Speaker 1 12:55 And you know that makes sense, because so much of your potassium is inside your cells, so 98% inside your cells, 2% is out. So if you have a low serum potassium, you probably have a very low intracellular potassium as well. You're going to have to give that patient, sometimes several 100 mill equivalents over several days to kind of replete up their intracellular potassium. That will eventually end up repeating their serum potassium as well. So for people with very significant hypokalemia, another clinical Pearl here is that you can't just give them a supplemental dose and expect everything to be good. You're going to potentially have to give them a lot of potassium over a period of a day or two to get to where you need to be for that patient, right? Dr. Khyati Patel 13:41 And then, you know, good thing for patients who are in the hospital, there is a possibility of checking the chem panel more frequently to see you know how you want to dose the patient. Dr. Kane, we talked about foods that contain potassium. What are some other over the counter ways or products that are available that we can use for potassium supplementation. Speaker 1 14:03 Yeah, and you know, Dr. Patel, I would imagine that some patients, when they hear that their potassium is low, they might go to a pharmacy and look for potassium supplements, and they're likely to see something like potassium gluconate 550 milligrams. And that sounds really good, except potassium gluconate 550 only contains 90 milligrams of potassium, which is about 2.5 mEq of potassium. So it's like a quarter of a banana. So you'd have to take four of those to equal one banana, and at some point you might as well just buy a banana. So I don't really see a role for this one because the dose is so low and you'd have to take so many tablets, but it's really the only commonly used oral, solid dosage formulation that you're going to see for a potassium on the over the counter side. Dr. Khyati Patel 14:48 And probably much more expensive than a banana too, because you go to Trader Joe's, they haven't changed their prices of banana. It's still 19 cents. Unknown Speaker 14:56 cents. Absolutely, yep. The Dr. Khyati Patel 14:59 other thing I. Hear a lot of times patients talk about, especially those who have hypertension and they want to avoid sodium, is using salt substitute. Because salt substitute, you know, as the name suggests, contains potassium instead of containing sodium. How does that work? Are they helpful or not? So? Speaker 1 15:17 Dr. Patel, these products are basically sold as what looks like a salt shaker, so you might see brands like NoSalt or just generic salt substitute, and about a quarter of a teaspoon contains 20 mEq of potassium. So that that's kind of what we're looking for. Like 10 to 20 mEq per dose is pretty normal for potassium repletion. Different products have different mixtures. So you do have to be careful, because one product that is a salt substitute may actually contain a little bit of sodium in it and less potassium, or vice versa. And Dr. Patel, have you ever tried any of these products? Dr. Khyati Patel 15:50 No, I have not. The extent of me trying anything other than table salt is Mrs. Dash, and I know they don't. They don't have a whole lot of potassium Speaker 1 16:00 in them. Yeah. So I have tried salt substitute, and I can confirm it is atrocious. And if you go to the Amazon for any of these products, some of the quotes that really stuck out to me were, quote, it tastes nothing like salt, which is true. Quote, it has a horrible chemical flavor, and truly tasted like I imagined it would be to eat detergent, quote, bitter, metallic taste. And then one of my favorites is I would rather deal with high blood pressure, or I would rather eat bland food. It really has no resemblance to table salt at all. It does have like a chemically bitter taste to it. This is not a good option for culinary reasons. But also, you know, if you were to ask a patient to ingest this every single day, it would be very unpalatable for a patient to do that Dr. Khyati Patel 16:51 and putting on my risk versus benefit hut, right? It doesn't have a benefit, meaning, you know, the taste is horrible. You're not getting that satisfaction. But on the flip side, you mentioned 1/4 of a teaspoon can contain 20 milli equivalents, so if somebody could even tolerate it and it's palatable for them, they could accidentally ingest a lot of potassium, isn't it? Yeah. Speaker 1 17:13 I mean, I have seen alerts or comments in different patient education pamphlets and things like that for ACE inhibitors to avoid salt substitutes. So the thought there is that if you have a medication that causes hyperkalemia, you don't want a patient ingesting extra potassium. But I would say, generally speaking, nobody likes taking these. It would be pretty difficult to actually get a patient to have an appreciable amount that they take every single day. But certainly you're going to have those patients out there that do that, and that would be something that you'd be concerned with, definitely. Dr. Khyati Patel 17:43 So patient education, you know, make sure that you are evaluating some of these dietary changes that patients might be making to, you know, in their best intention to help them their potassium, but it could be harming them too. So we talked about foods. We talked about, you know, maybe these potential over the counter, quote, unquote, supplements. What about prescription products? What avenues do we have? Speaker 1 18:08 So in terms of oral we have a liquid and a powder. So the powder is very similar to the salt substitutes, where you're going to be typically mixing it with a liquid and ingesting it, and then the liquid is just pre mixed for you in water, these still taste terrible. It's the same thing. So really, the only time that these are used are for people, like in the ICU, for example, that have feeding tubes where they don't taste it, because the tube goes from outside of their mouth all the way into their stomach, and it bypasses their tongue. So in those situations, it can be nice, because you actually cannot crush the solid formulations, the capsules or the tablets. So we can use it for those patients, but typically we're not going to use it in someone who is eating by mouth. Dr. Patel, I'm sure you've seen a lot more of the kind of solid dosage forms or slow-release preparations, right, right? Dr. Khyati Patel 18:58 Yes, the powder packets taste horrible. So I've not seen a whole lot of patients who have po access using them, and so for them, we use this low release preparation. You know, a couple different formulations are available, and the slow release formulation, and you kind of alluded to this a little bit earlier, that the solid dosage form could have a little bit more GI irritation. You know, it's just higher concentration of potassium that happens during the dissolution. So there's like a spot irritation that can happen in the GI lining. And therefore, you know, we have these slow‑release preparations – the idea is that instead of dumping all the potassium at once, it releases over the course of time. So you know, it's less irritating to the GI lining. And when we say irritation to the GI lining, you know we're talking about ulcers, potentially or even bleeding. And so we have to then alter to or use these slow‑release preparations. As the name slow release, though, comes with that you can't crush them. And so a couple different formulations are our sprinkle capsules, as well as some tablets, two main tablet formulations, Speaker 1 20:13 yeah, and the sprinkle capsules. Those come as eight or 10 mil equivalent capsules. So again, that's a typical dose that we're working with. So a banana worth, if you will. These are generic, fairly inexpensive. You open up the capsule, you can sprinkle the beads, which are slow-release beads under foods like applesauce. As long as you don't chew it, you're good to go in terms of something like that. Yep. Dr. Khyati Patel 20:35 And then our two tablet formulations are the Klor-Con and the Klor-Con M. And the way they're formulated is slightly different. So that's the difference between the M and the one that's non M. The Klor-Con without the M has the wax matrix, so your active medication is kind of packed into it, kind of like your Metformin extended release versus Klor-Con M. The M stands for micro encapsulation of your potassium chloride crystals. Speaker 1 21:08 And the benefit there is that potentially you get a slower dispersion when the tablet gets disintegrated in the GI tract. So potentially this could be less irritating to the GI lining than the wax matrix formulation. But interestingly, there's basically no data to actually support that, so it's more of a theoretical benefit, kind of like enteric coated aspirin in terms of a lower risk of GI bleeding with it. There's not a lot of data for that either. But in this case, with Klor-Con M, this microencapsulation technology basically doesn't cost any more. The cost per tablet is fairly similar between Klor-Con and Klor-Con M, and if it makes you sleep better at night or feel better that you have this advanced technology that might cause less GI irritation, I don't see any harm in picking one versus the other. It's kind of either one would be reasonable to use. Dr. Khyati Patel 21:57 What about on the parenteral side? Let's say a patient was in a hospital and we needed to replete the potassium, and they don't have PO access. What options do we have? Speaker 1 22:07 So for those patients, our typical strategy is going to be giving IV potassium chloride, and it's just mixed in water. The repletion typically does not have other ions in it, like normal saline or anything like that. It's literally potassium chloride and free water. Typically the bags contain either 20 or 40 mEq of potassium per bag, and usually the difference is how much water is in them. So for example, we have a 40 mil equivalent in 100 ml formulation that is very concentrated. That particular formulation we only use when patients have central lines, versus lower concentration, or more diluted concentration we would use for peripheral IVs. And the reason for that is that when we give IV potassium, it can cause a lot of phlebitis or vein irritation. Patients will complain that it hurts to have it infused. And the strategy there is to either give it slower or give it in a more diluted fashion. But I've seen tons of patients that even when we give it, you know, half the speed at a more dilute concentration, it's very common that patients will still have some amount of discomfort or phlebitis or irritation caused by the IV potassium. So that is something that we need to worry about. Dr. Khyati Patel 23:23 And the other thing you mentioned, Dr. Kane, is we can control the rate of infusion to avoid some of, some of the phlebitis, type of irritation that comes along. I assume that rate has also, you know, in addition to phlebitis, to do with safety. And so what's the normal infusion rate for potassium chloride, Speaker 1 23:41 IV, yeah, the standard infusion rate is going to be 10 mEq per hour. So that means that if you're giving a patient 40 mill equivalents, you have to wait four hours for that bag to infuse into the patient. And very SELECTED CONDITIONS, you might go up to 20 mEq per hour if the patient has, like, a very dangerously low potassium level, and you have the ability to continuously monitor an EKG for that patient, because you're worried about arrhythmias. And this is really important, Dr. Patel, and the reason is that if you give potassium too quickly, it can cause the patient's heart to stop working. This is actually one of the meds that is given in certain circumstances for lethal injection. They give a very large dose of potassium as an IV push, as opposed to over some period of time. So the heart doesn't like a lot of potassium all at once. So it's really important that we only infuse it at 10, maybe 20 mEq per hour, never more than that. Dr. Khyati Patel 24:33 So an effective strategy, but we still have to be very careful and safe with this exactly. So, Dr. Kane, we have the, you know, the IV products and the chronic supplementation, po products. How do we decide to go with IV versus Po? Because some patients who are in the hospital may still have po access. So how do we decide whether we want to go with IV or Po? Speaker 1 24:57 Yeah, I would say as a general rule of thumb, if you can get a. Way with Po. That's the way to go, because so many patients will have intolerances to the IV phlebitis that can occur. So obviously, if a patient can't take Po, they're strict in Po, they can't swallow anything, and you don't have the ability to give them a tablet, then of course, you're going to give them IV. Keep in mind that we do have those liquid and powder based products, so if they have a tube, we can put that down a tube into their stomach, and they won't ever taste it. Dr. Khyati Patel 25:27 And what about if the potassium is very low, like dangerously low? Would would IV be better than using Po? Speaker 1 25:36 It is. So for a typical scenario, would be like a diabetic ketoacidosis or a DKA patient, those patients can have precipitous drops in their potassium. So for someone like that, we do give them IV because we want to make sure that they're getting it, and we want to make sure that, you know, we're being aggressive and giving it to them. Sometimes we will give them po plus IV, but typically we're going to give them IV when we really want to make sure that we're repleting it as soon as possible. Dr. Khyati Patel 26:01 And like we established earlier, right? The potassium is the intracellular. So, like we are giving more aggressive IV doses, it still takes time for body to shift them from serum to intracellular, you know, potassium concentration. So that's the reason to go after IV as Speaker 1 26:17 well, exactly. And one other thing to think about Dr. Patel is, you know, we already established that humans need about 50 to 100 mill equivalents per day of potassium, and if you don't get it, eventually you'll get hypokalemic just because you don't have enough intake. One thing that comes up very frequently on the inpatient side is, you know, for someone who's going to be NPO, so nothing by mouth, no diet for several days, at some point, we probably need to give them potassium as part of their maintenance IV fluids to make sure that we avoid that hypokalemia. Dr. Khyati Patel 26:49 And you're saying this because the maintenance IV fluids normally don't contain any potassium, and so yeah, they might be getting that maintenance IV fluid, but then it doesn't have potassium. So like you said, we need to give them something else on top of it, to include potassium. Our maintenance IV fluids are usually our normal saline or half normal saline or dextrose. Speaker 1 27:14 Yeah, and all three of those, D 5w, N S, half n s, they don't contain any potassium. So if you continue to do those, even d5 half normal saline, which is a commonly used maintenance IV fluid, all of those contain no potassium. So if you continue using those for several days, a patient is going to have potassium problems. So in lieu of that, the better thing to do is there are maintenance IV fluids that contain potassium, on purpose for this reason, and manufacturers will actually have pre mixed bags of something like d5 normal saline with 20 mEq per liter of potassium, or d5 half normal saline with 20 mEq of potassium in it. And the intent here is that a typical patient is probably going to get about two liters per day of IV fluid, depending on what rate they're on. So that means that they're going to get roughly 40 mill equivalents per day of potassium through these formulations that are intended as maintenance IV for the NPO patient. So for someone who's going to be on IV fluids strict NPO for several days, it typically is a good idea for them to have a little bit of potassium in those IV fluids. Obviously, if they're hyperkalemic or have acute kidney injury, there are exceptions to the rule, but generally speaking, for that, the healthier acutely ill patient, they're probably going to need some amount of potassium in those IV fluids. Dr. Khyati Patel 28:32 And then we have some IV fluids that contain a little bit of potassium in them, because they are kind of mimicking our natural electrolyte composition. One comes to mind is Lactated Ringer's, which contains about 4 mEq per liter, so again, not nearly enough alone, but it has other electrolytes as well, not just potassium. Other examples are Plasma-Lyte, Osmolyte, and Isolyte. These solutions also contain about 5 mEq of potassium per liter. But if you think about it, at normal IV fluid rates, most patients are going to get about 10 mEq, again, equivalent to eating a banana a day, and not more. So, while you think that these fluids contain potassium and a patient would get some potassium, in cases of hypokalemia the repletion needs might be greater, and these fluids may not provide what you need per day. Speaker 1 29:31 Interestingly, Doctor Patel the the converse of that is that if a patient has a higher potassium level, lactated ringers, plasma, light and other products, they typically are not going to cause hyperkalemia because they have so little potassium per liter of other IV fluid. And we've actually done studies on this where we've compared things like lactated ringers with a little bit of potassium versus normal saline that has no potassium. And in those studies, patients potassium levels. Don't differ at all. So the converse of there's really not much in there, meaning that it won't supplement is also typically won't cause hyperkalemia either, just because there's not very much in there. Dr. Khyati Patel 30:11 And that is great to know. Well, Dr Speaker 1 30:14 Patel, why don't we go back to George, our patient case. So this was our heart failure patient. New diagnosis started on furosemide a week ago. We did our Chem seven A week later, after starting that Lasix, and now his potassium is low at 3.2 he's completely asymptomatic. And really the question is, do we do anything for George? And if we do, what is the best strategy for him? Dr. Khyati Patel 30:36 And so depending on who you ask, you know the goal is kind of shooting in the middle of that range for but if the patient is asymptomatic on outpatient cases, you know, you could also keep the goal, as you know, as long as you bring them within the range. So 3.5 get to get to that would be okay as well. Speaker 1 30:55 And obviously he's not going to get admitted to the hospital. So probably, if we were to replete him something oral makes more sense than IV, right? Dr. Khyati Patel 31:03 Absolutely, we're not gonna, you know, hook him up to an IV line. And in this case, especially, he's outpatient, asymptomatic. It is obvious that patient's gonna need to continue the diuretic. We're not gonna stop it because of the new onset heart failure. And so, given the benefits of furosemide in heart failure patients, we're probably going to need chronic supplementation. And so po therapy sounds absolutely fine. We can consider any of the PO formulation, probably not the immediate release packets, but more on the slow release side. So either Klor-Con or Klor-Con M, Speaker 1 31:42 you know, a reasonable dose would be something like 20 mEq that he could take once a day, or maybe twice a day. If you did do twice a day, so he's getting 40 a day, that would be kind of on the higher side. So probably you would back that off after a week, once you kind of get him back to where he needs to be. So if you did 20 B ID, maybe 20 daily once you're happier with his potassium, yeah. Dr. Khyati Patel 32:03 And then you can also educate him on foods that contain potassium in order to reduce the dose of, you know, supplemented potassium. And so that can also help to back off a little bit. And then we obviously want to check patients potassium after starting this therapy in about a week or so that you know, we've achieved our goal, or normal potassium goal, and then at that time, might as well check the magnesium, because we want to make sure, as you said earlier, Dr. Kane, you know, patients magnesium level is not within the range. Then you're going to keep chasing this potassium with no avail. Speaker 1 32:40 From a patient counseling perspective, certainly we need to talk about foods, but also just from a side effect standpoint, it's important for George to know that it can cause some GI irritation, and if that happens to him, there's no harm in combining this with breakfast, lunch or dinner. So you can take it with food to help with some of that GI irritation, because again, the thought here is that the GI irritation is driven by too much potassium, too localized in the GI tract, and if you can kind of dilute out the potassium with other food that may help with some that irritation, absolutely. Dr. Patel, just for clarity, do you have any favorite foods that you would recommend George to try to supplement with so maybe he doesn't need as much of that potassium supplement. Moving forward, Dr. Khyati Patel 33:22 yeah, like, you know, I am normally careful recommending foods with potassium because most of my patients have diabetes. So although I would love to say, hey, buy those 19 Sun bananas, sometimes they do more harm than help. And so, you know, I try, I try to evaluate, you know, other conditions that they may have too, but lots of leafy greens, you know, if they can, you know, obviously not war in patients. But greens contain good amount of potassium too, and so kind of balancing things out, some nuts and dried fruits like raisins and figs, have them too. So, yeah, a little bit of everything, depending on, you know, where they are in their therapy and their medications and disease states, perfect. Speaker 1 34:04 Well, Dr. toe, what are some key take home points that you'd love for the listeners to recall from today's episode? Dr. Khyati Patel 34:10 Well, so going back to, you know, diet, most diet will provide enough potassium in a daily you know, allowed amount to avoid that hypokalemia. We're thinking of hypokalemia. The causative factors are usually medications like diuretics, or somebody who has, you know, stomach losses, like gi losses, like severe vomiting or diarrhea. And that usually is because of an underlying condition, or acute underlying condition, Speaker 1 34:40 and then for that patient with chronically low potassium, usually, a typical starting regimen is going to be to give them 20 to 40 mEq per day of extra potassium, typically through the slow release tablets. On the inpatient side, if we went to acutely replete a patient because their potassium is low, the rule of thumb is. That for every 10 milli equivalents of potassium chloride you give, it should increase the serum potassium by about 0.1 milli equivalent per liter. Dr. Khyati Patel 35:08 So when we talk about supplementing it on the outpatient side, you know, our over the counter potassium supplementation, such as potassium gluconate, has very, very small amount of potassium you're talking you know, 2.5 milli equivalent. So that might not help entirely, but our prescription products, like potassium chloride powders, liquids and the extended release, low release formulations might be helpful. The powders and the liquids, you know, as we establish, they don't taste good at all and they're poorly tolerated, so we limit them to patients who are on two feeds, but most patients will be prescribed those low release tablets like the Klor-Con or Klor-Con M, or those sprinkle capsules, or better palatability. Speaker 1 35:51 And then finally, for that inpatient, hospitalized patient who is NPO not taking anything by mouth, eventually, after a couple days, they're going to need some potassium supplementation. And the typical IV fluids that you think of as an IV fluid usually don't contain very much potassium at all, so normal saline has zero lactated ringers has four per liter. So usually these patients will eventually need some maintenance IV fluid that does contain something like 20 mEq per liter of potassium. So that typically means that they're going to get two liters of that, so about 40 mEq per day through that IV fluid. The key here is that we're acknowledging that those NPO patients will need some potassium at some point, unless other factors are going on, like bad renal impairment or other reasons that they would have an abnormally high potassium for a long period of time. So Dr. Patel, thank you so much for today's episode, I think that we covered hypokalemia repletion monitoring quite well for the listeners. If you want to see our show notes, they're at HelixTalk.com episode 157 we're also on Twitter at HelixTalk, where we release clinical pearls from previous episodes. And we have a mailing list where you can get an email every time a new episode comes out, with the show notes in your email inbox every three weeks on Tuesday. So with that, I'm Dr. Kane Dr. Khyati Patel 37:03 and I'm Dr. Patel, and as always, study hard. Narrator - Dr. Abel 37:07 If you enjoyed the show, please help us climb the iTunes rankings for medical podcasts by giving us a five star review in the iTunes Store. Search for HelixTalk and place your review there Narrator - ? 37:19 to suggest an episode or contact us or online at HelixTalk.com thank you for listening to this episode of HelixTalk. This is an educational production copyright Rosalind Franklin University of Medicine and Science.