Why do more when you can get by with less ! Sounds like a good mantra for life to me ! This might also be true for IV Insulin dose to treat Hyperkalemia (High Potassium levels). The traditional teaching has been 10 units of IV regular insulin with D50 amp dose for elevated potassium besides other slower treatments that push potassium intracellullarly (Albuterol nebs, bicarb etc) – which is a quick (acts in 15 mins) but temporary bandaid fix buying us time to prevent cardiac effects while we figure out how to expel excess potassium out of the body.
Studies in the last few years now show that a lower dose of IV Insulin – 5 to 6 units – can also be effective in dialing down potassium levels while also avoiding hypoglycemia. For example, this study published in 2020 looked at Ninety-two administrations of reduced dose of 5 Units insulin and 309 administrations of conventional dose insulin for potassium greater than 6 mmol and found similar efficacy of lower potassium , except when levels exceeded 6 mmol . Another retrospective study published in 2018 noted 5 units was as effective in as 10 units at least in dialysis patients minus the hypoglycemia. A Meta-analysis of 10 different restrospective studies published in 2021 arrived at the same conclusion. Quality over Quantity ! Win-Win ?
However, this “quasi-study” published in 2022 comparing efficacy of insulin before and after implementing an orderset of 5 units Insulin as a choice did not show that 5 Units Insulin was very effective in treatment Hyperkalemia in patients on regular dialysis – but the structure and details of the study aren’t clear to me.
💡 My Take: While we need bigger and better structured studies, I use 5 to 6 units in patients with AKI or End-stage renal disease OR if they have baseline / normal renal function but potassium elevation is less than 6.5. Also consider lower dose if glucose is low to normal to begin with. Of course if cardiac effects are already visible with Hyperkalemia (Peaked T-waves, bradycardia ) then all bets are off and I order 10 units besides other treatments – but maybe use 2 amps of D50 in that case if Glucose if not super high !
