CME/CE Podcast: Emerging Options for Managing Hyperkalemia in Challenging Patients

For more information regarding this CME/CE activity and to complete the CME/CE requirements and claim credit for this activity, visit:

https://www.mycme.com/courses/management-of-hyperkalemia-in-high-risk-patients-8850

Featuring faculty George Bakris, MD, moderated by Gregg Sherman, MD.

Summary
Hyperkalemia is a common condition in certain patient populations and can increase risks for hospitalizations and mortality. The limitations of traditional treatment approaches make management of high-risk patients challenging, particularly in those with chronic kidney disease (CKD), heart failure (HF), and hypertension. However, new and emerging treatment options are available for the management of hyperkalemia and may improve outcomes in these patients.

In this second of two podcast episodes, Dr. George Bakris and Dr. Gregg Sherman discuss new and emerging treatment options for the management of hyperkalemia, and how to incorporate these therapies most effectively for patients with CKD, HF, and hypertension.

This podcast was recorded and is being used with the permission of the presenters.

This CME/CE podcast is available for credit on myCME. Click the button on the right to listen now.

Learning Objectives
Upon completion of this activity, learners should be able to:

• Incorporate current and emerging therapies into the management of hyperkalemia in patients with CKD, HF, and hypertension based on recent clinical trial data

This activity is accredited for CME/CE Credit.
The National Association for Continuing Education is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians.

The National Association for Continuing Education designates this enduring material for a maximum of 0.25 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

National Association for Continuing Education is accredited by the American Association of Nurse Practitioners as an approved provider of nurse practitioner continuing education. Provider number: 121222. This activity is approved for 0.25 contact hours (which includes 0.25 hours of pharmacology).

Summary of Individual Disclosures
George Bakris: has disclosed the following financial relationships:

• Consultant: Bayer (Diabetic Kidney Disease), KBP BioSciences (Hypertension), Ionis (Hypertension), Alnylam (Hypertension), AstraZeneca (Hyperkalemia), Novo Nordisk (Diabetic Kidney Disease), Janssen (Hypertension), inRegen (Kidney Disease)
• Contracted Research: KBP BioSciences (Hypertension)

Angela Golden has disclosed the following financial relationships:

• Consultant: SetPoint (Obesity), WW (Obesity)
• Advisor: Currax (Obesity), Genesis (Obesity), Lilly (Obesity), Novo Nordisk (Obesity), (Obesity), Acela (Hypothyroidism)
• Speaker: Currax, Novo Nordisk (Obesity)
• Receipt of Royalty: Amazon (fiction books), Springer (obesity book)

Faculty, planners, guest patient(s) (if applicable), and moderators for this educational activity not listed in the Summary of Individual Disclosures above have no relevant financial relationship(s) to disclose with ineligible companies whose primary business is producing, marketing, selling, re-selling, or distributing healthcare products used by or on patients.

Disclosure of Commercial Support
This educational activity is supported by an independent educational grant from AstraZeneca Pharmaceuticals.

Please visit  http://naceonline.com to engage in more live and on demand CME/CE content.

Transcript

Gregg Sherman, MD 0:21

Welcome to NACE Clinical Highlights. I'm Dr. Greg Sherman, chief Medical Officer at nace. This is the second episode in a two-part series on recent updates in managing hyperkalemia in patients with heart failure, CKD, and hypertension. Joining me is my friend and colleague, Dr. George Bakris. Dr. BCRs is director of the a h a Comprehensive Hypertension Center and Professor of Medicine at the University of Chicago Medicine in Chicago, Illinois. So glad you could join me today, George.

George Bakris, MD 0:51

Thanks, Greg. Good to be here.

Gregg Sherman, MD 0:54

George, in this second podcast activity, we're gonna discuss newer therapies for management of hyperkalemia and how our colleagues listening can incorporate these agents into their clinical practice. So to set the stage, I thought it'd be great to begin with a case so everybody could picture this patient in their practice. This is a typical case of a 66 year old man with HFrEF and reduced kidney function with an E G F R of 40. Blood pressure's 1 35 over 80, heart rates 88, and he has two plus pitting edema. His history is significant for constipation. Recently he achieved optimal therapy for HFrEF through dose titration, which include RAs inhibitor losartan at a hundred milligrams daily. Unfortunately, his potassium in your office follow up is now at 5.7 up from his baseline of 4.6. George, this typical patient treating for HFrEF potassium goes from four six to five seven. I wonder if you can tell us about some of the newer options for managing hyperkalemia that our colleagues may reach for.

George Bakris, MD 2:01

It is pretty clear that this person is gonna need some kind of enabling therapy, which means potassium binders. I say that because if you stop the medications specifically, the angiotensin receptor blocker is on losartan or the mineralocorticoid receptor antagonist which is probably spironolactone, which is indicated in this patient. He's not gonna get maximal therapy. And you really shouldn't deny a maximal therapy. So one of the things that you can do is stop the losartan and give him sacubitril Valsartan, which is gonna give him a better diuretic effect and help your potassium a little bit in that way. But more importantly, they're gonna need, he's gonna need some kind of binding. Of potassium to get rid of it since his kidney is unable to deal with it and he's got factors working against him. So there are two agents that are available besides S ps. One is Piter, also known as Veltassa, and the other one is Sodium Conium. Cyclosilicate, also known as Loma. Now these agents are both. Potassium binders, and they're both very well tested, they're approved, and they've been around for at least seven to eight years. So they're not new in that regard. And the major difference between these two agents and S P s is they're well tolerated. They can be taken daily. And in fact, both these agents have been tested with daily use for one year. And these are published. One is in jama, the other one is in clinical, Jason. These are major journals clearly documenting the chronic use of these agents as enablers of proper therapy in patients whose kidneys really can't handle the potassium Now. Again, very important that you think of these agents to enable proper therapy in the patients that need it. And the thing is, everybody's worried about these agents. The major side effects of these agents are nothing like S sps number one. Piter has constipation as a major side effect. This patient has constipation, so that's not an agent that you're gonna jump to in somebody like this. And the other difference between the sodium zirconium cyclosilicate is that this is a calcium-based binder, whereas s E C is based as a sodium binder. So it's very different from a chemistry standpoint. Number two, the side effects tend to be different. Piter has side effects of hypomagnesemia, which is very, very small change in magnesium. It doesn't really cause true hyposmia. But it is gonna lower magnesium to the tune of maybe 0.1 or 0.2 milligrams per deciliter. That's number one. If you give it excessively, it can cause hypokalemia, but constipation is by far the most common side effect. S E C on the other hand, is a sodium based molecule. It's a totally different chemistry, and it comes as three doses, five grams, 10 grams, and 15 grams. And as you can imagine, At higher doses, edema is an issue. Now you could say, wait a minute, this guy's got heart failure. He's already got edema. We, need to not think about that. The truth is that a doses of five or 10 grams, which I've used a lot, The reality is edema is a very minor factor, especially if you're giving proper diuretics. It's really not a big deal even at 15 grams it really, while it's more of a deal, it actually can be easily managed. I think. Those are important issues. The other important issue is piter cannot be given at the same time as all the other medications because there's some binding. However, there's only three medications that really are an issue. Metformin, thyroid medication, and an antibiotic which I don't remember, but basically, The majority of medicines are fine, and if you leave three hours, which is the updated label between dosing, you're fine with that drug. S e c really doesn't have any major binding that's been shown, but for as a precaution, you can allow some time in between medications as well there. I think it's important to know that you have not won, but two. Very safe options that you can use in a patient like this, and it will enable this therapy to take its action. what you need to appreciate, and cardiologists I know, appreciate this, that after about four to six months, the heart will improve dramatically. Guess what happens? When the heart improves dramatically, kidney function improves, so you may not need it down the road. And that's something that you have to understand could happen. So I think it's important that you know about these agents, that you use these agents appropriately and at least in my experience, insurance coverage for these agents, which was previously difficult, is now much more flexible. That should not be an excuse not to use these agents.

Gregg Sherman, MD 8:02

George, I think that was really helpful in setting the stage and clarifying these agents, but I wonder how quickly these agents will work to decrease potassium levels in our patients at risk.

George Bakris, MD 8:15

Both these agents within 24 hours clearly are gonna start showing you reductions in potassium. This is well documented, and what's interesting is with. Pater the evidence is that you're actually seeing some effects within the first six to seven hours. With the sodium, with the s e c there's actually data that you can see effects within the hour, but part of that is not so much from binding, it's from bicarbonate changes that are an extra plus of potassium being pushed into the cell, but definitely within 12 hours. Both these agents are giving you benefits and they're not going to cure hyperkalemia, but they will take you out of the danger zone hyperkalemia.

Gregg Sherman, MD 9:08

How far after starting these medicines should colleagues be rechecking potassium levels.

George Bakris, MD 9:14

if you're really very nervous, you can recheck the potassium in three days, two, three days, because it definitely will be down by then. Because I'm more familiar with this data I don't check it until about a week because at that point you should be in a steady state, and, you should see what the actual potassium is. But if you wanna see reduction, you can check it in 24 hours if you want, we're not running an emergency room as an outpatient. So I would say two to three days, you definitely will see something that's significant. But I would say a week.

Gregg Sherman, MD 9:50

The final follow up to this: are there any particular charting requirements that our colleagues should be aware of to get insurance approval for any of these agents?

George Bakris, MD 10:02

I think what you need is you need documentation that the patient has heart failure or advanced kidney disease or both. That's number one. And then number two, that they're on these therapies that are required per guidelines, and then they have a potassium problem. If you have all that, that's really all you need.

Gregg Sherman, MD 10:28

Putting it all together would be helpful for our colleagues to learn about your approach to managing hyperkalemia in these patients who also have c k d, heart failure and hypertension. so they might see what you're doing in your practice.

George Bakris, MD 10:43

I try to identify people in advance that I think are gonna have a problem with this, that are gonna require this therapy. I only need to know two things. Number one, what's their G F R? If it's below 45, I know they're gonna be at much higher risk. Number two, what's their potassium at baseline on diuretics? On diuretics, that's important. And if the potassium is greater than 4.8, I know for a fact that those two groups of people are definitely gonna have a problem with potassium. So I preempt that by warning him about diet. And I give him a handout. You can go to kidney.org and get, this is from the National Kidney Foundation. And then the, patient can refer to that for low potassium foods. Now, most patients are not gonna stick with that diet. Let's, be honest, they will try, but after a week or so, they're coming off. So I know this and so in anticipation what I'm gonna do is I'm gonna check their potassium after I start the therapy within a week and see where it is. If it's elevated, and I know this is mandatory therapy, I'm not gonna play with the doses and all that because we know if you're not giving the doses used in the clinical trials, you are not getting the outcomes that you think you're getting. A lot of people are under that impression. There's five papers in the literature that clearly show that's not true, so they need a binder. I will write for a binder in that situation and I will start them off encouraging them to stay on the low potassium diet, and I will start them off using it three times a week so that they don't feel like they have to take it every day. And then I'll recheck'em three times a week after a couple of weeks and see where they are. I've found in most people, That three to four times a week is all they need the binder for. They don't need every day. They can take it every day. And there may be some that don't wanna sacrifice the diet, at which point you definitely need it every day. But if they're willing to work with a diet, you can get by with three or four times a week. that's what I do.

Gregg Sherman, MD 13:04

That's helpful for all of us in managing these patients, which are increasingly complex and require multiple medications to optimize their care. George, I think this has been terrific and I really want to thank you for taking the time to speak with me and our other colleagues listening to share your expertise in managing hyperkalemia and overcoming the barriers to treatment that often may occur in these high risk patient populations.

George Bakris, MD 13:28

Thank you very much, Greg, for having me. It's been a pleasure.

Gregg Sherman, MD 13:33

If you're interested in learning more about recent developments in the management of hyperkalemia and high-risk patients, join us for the first part of my discussion with George titled Hyperkalemia and the Limits of Traditional Management. You can also go to the NACE website@naonline.com and register for any of our other enduring activities on hyperkalemia, heart failure, ckd, or any other program we've developed. Please like us on Facebook at NA C M E to be part of our online social media community and get access to other content and programs we share. And finally, I want to thank you, our audience for joining us for this podcast. I hope you've learned something new you can bring back to your practice. We look forward to having you join us for other upcoming podcasts in the future.