2025 Southeastern Residency Conference

Title:
Efficacy and Safety of Reduced-dose Insulin for the Treatment of Hyperkalemia in the Emergency Department 
Authors:
Blake Henderson, PharmD; Cortney Storey, PharmD, MBA; Cassey Starnes, PharmD, BCPS; Kevin Sullivan, PharmD, BCCCP; Elsa Hendrick, 2026 PharmD candidate; Jessie Lipstreuer, PharmD, BCEMP
Objective:
The purpose of this study was to assess the efficacy and safety outcomes between patients treated with reduced-dose versus standard-dose insulin for the treatment of hyperkalemia in the emergency department
Self-Assesment Question:
What is the recommended standard IV insulin dose for the treatment of hyperkalemia in the emergency department?
Background:
Hyperkalemia is a common, potentially fatal electrolyte abnormality. Hyperkalemia occurs in 1% - 10% of hospitalized patients with up to 2% - 3% identified in the emergency department. Recent estimates have shown that hyperkalemia leads to more than 800,000 annual emergency department (ED) visits in the United States with a growing prevalence due to an aging population with associated comorbidities
Methods:
This single-center, retrospective, IRB-approved study evaluated adult patients who received intravenous (IV) insulin, either reduced dose of 5 units or standard of 10 units, for the treatment of hyperkalemia from January 1, 2020 to July 31, 2024. Exclusion criteria included patients who received IV insulin for indication other than hyperkalemia, missing repeat labs within 12 hours of insulin administration, and receipt of emergent dialysis prior to first repeat potassium. The primary outcome was median change in potassium, defined as change from baseline to first repeat potassium, then from 4-18 hours post administration of the first dose of IV insulin. Secondary efficacy outcomes included repeat IV insulin doses required for persistent hyperkalemia within 12 hours, change in blood glucose (BG) at 1, 6, and 12 hours post IV insulin, additional dextrose given within 12 hours of initial IV insulin, pathway compliance with appropriate initial insulin dose and initial appropriate dextrose given for patients with a BG < 250, and hospital length of stay. The primary safety outcomes included incidence of hypoglycemia (BG <70 mg/dL) and severe hypoglycemia (BG < 54 mg/dL). IV insulin. Data was sourced from the electronic medical record and collected using REDCap and statistical analysis was conducted using SPSS. Continuous data was assessed using Student’s t-test or Mann-Whitney U test. Categorical data was assessed using Chi-square test or Fisher’s exact test.
Results:
Forty-six patients were included in the standard dose insulin group and ninety patients were included in the reduced dose insulin group. The primary outcome, mean change in potassium, was not significantly different between both groups [95% CI: -0.296 to 0.236; p=0.83) or at 4-18 hours post IV insulin administration [95% CI: 0.429 to -7.346; p=0.43]. For secondary efficacy outcomes, there was no statistically significant difference in glucose levels at baseline [95% CI: -45.935 to 13.849; p=0.29), 6 hours [95% CI: -36.146 to 19.566; p=0.56], or at 12 hours post IV insulin administration [95% CI: -33.120 to 20.129; p=0.63]. For safety outcomes, no statistically significant difference was found in incidence of hypoglycemia (10 vs 22 patients, p = 0.52) or severe hypoglycemia (6 vs 10 patients, p = 0.91) in both groups.
Conclusions:
In this retrospective, observational study, there was no difference found in median reduction of potassium levels with standard dose IV insulin vs reduced dose IV insulin. No significant differences in secondary safety and efficacy outcomes were observed.