Approach to patients at risk for hyperkalemia caused by inhibitors of the renin-angiotensin-aldosterone system

Estimate glomerular filtration rate to assess specific risk of hyperkalemia

Discontinue nonsteroidal antiinflammatory drugs and other drugs that interfere with renal potassium excretion

Inquire about use of herbal preparations

Prescribe a low-potassium diet

Inquire about use of potassium-containing salt substitutes

Prescribe thiazide or loop diuretics to increase potassium excretion

Prescribe sodium bicarbonate to correct metabolic acidosis if present

When initiating ACE inhibitor, angiotensin receptor blocker, or mineralocorticoid receptor antagonist, use low doses

Measure serum potassium concentration one week after initiating therapy or after increasing dose of these agents

If hyperkalemia develops (refer to content on specific drugs for thresholds), reduce or discontinue the drug(s) causing hyperkalemia.

ACE: angiotensin converting enzyme.

Adapted from: Palmer BF. Managing hyperkalemia caused by inhibitors of the renin- angiotensin-aldosterone system. N Engl J Med 2004; 351:585.

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