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Is Kayexalate Effective for Hyperkalemia, and Is It Safe?

Recent evidence fuels growing concerns about use of sodium polystyrene sulfonate with sorbitol.

Sodium polystyrene sulfonate (SPS; e.g., Kayexalate) has been used as an oral or rectal therapy for hyperkalemia since 1958 — before the FDA required drug manufacturers to prove efficacy and safety in 1962. SPS is an ion exchange resin that is thought to exchange sodium with potassium in the colon. Because constipation is a common complication, SPS is often mixed with sorbitol. In a clinical commentary, the authors reviewed the literature on SPS and sorbitol from the past 50 years and found no evidence of clinically significant lowering of serum potassium in patients with hyperkalemia. The strongest evidence for SPS efficacy is a drop in serum potassium of at least 0.4 mEq/L in 23 of 30 hyperkalemic patients (Circulation 1952; 5:747). A recent report described colonic necrosis in patients treated with SPS mixed with sorbitol (South Med J 2009; 102:493). In September 2009, the FDA issued a warning about concomitant use of SPS with sorbitol, although this combination is currently still available.

Comment: As a nephrologist who has used sodium polystyrene sulfonate for decades, I found this review startling. Although I was aware that the beneficial effect of SPS was, at best, slow and gradual, I was unaware about the risk for intestinal injury when SPS is combined with sorbitol. Fortunately, more rapid and effective measures are available to lower serum potassium in patients with hyperkalemia. These therapies include intravenous dextrose plus insulin, inhaled β-2 agonists, and sodium bicarbonate. On the basis of this commentary and literature review, I discourage prescribing SPS with sorbitol as a first-line therapy for hyperkalemia.

— F. Bruder Stapleton, MD

Published in Journal Watch Pediatrics and Adolescent Medicine June 9, 2010

Citation(s):

Sterns RH et al. Ion-exchange resins for the treatment of hyperkalemia: Are they safe and effective? J Am Soc Nephrol 2010 May; 21:733.

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Reader Remarks:

Review and add to remarks on this article

• Another droperidol?
  Erik Deede, 14 Jun 2010 1:45 PM EST
  My understanding is that the other treatments you mentioned for lowering serum potassium (insulin/dextrose, inhaled beta-2 agonist, and sodium bicarbonate)... [more]
• other methods to lower potassium levels
  Cynthia D. Owens, 15 Jun 2010 7:12 AM EST
  I agree. The other modalities available to treat hyperkalemia has variable peak effects and duration effects, which at best last... [more]
• Review less than helpful
  Paul L Hacker, 16 Jun 2010 9:29 AM EST
  I agree with the other commentators - this review is less than helpful. The absence of evidence is not the... [more]
• SPS Old Time Religion
  Clyde H Sharpley, Hospital, 18 Aug 2010 8:54 AM EST
  You tell any Doctor that has been using something they think works, that it actually doesn't work, there will be... [more]

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