Hyperkalemia and Its Treatment: Real-World Evidence and Managed Care Considerations Supporting Use of Potassium Binders

An estimated 3.7 million adults in the United States have hyperkalemia. It commonly occurs in patients with chronic kidney disease (CKD) and/or heart failure (HF) and as a result of treatment with renin-angiotensin-aldosterone system inhibitors (RAASi), a class of medications recommended by professional guidelines for patients with CKD and those with HF. While lifestyle alterations have been previously recommended to control potassium levels for some patients with hyperkalemia, emerging evidence has shown a concerning pattern of chronicity and recurrence despite counseling to support lifestyle modifications. Real-world health outcomes among patients with hyperkalemia and recurrent episodes thereof have demonstrated higher risks of major adverse cardiovascular events, hospitalization, and mortality relative to patients with normokalemia. Similarly, real-world health economic studies have shown higher rates of health care resource utilization and higher medical costs. Together, these data hightlight the need for strategies that will restore patients' serum potassium levels to a normal range. Potassium binders are a pharmaceutical class indicated to treat hyperkalemia; sodium zirconium cyclosilicate (SZC), patiromer, and sodium polystyrene sulfonate (SPS) are guideline-recommended for patients with CKD, and the first 2 are considered potentially reasonable for patients with HF. Clinical trials and long-term open-label extensions studying SZC or patiromer support the safety and efficacy of these medications. Controlled clinical evidence supporting SPS's safety and efficacy is more limited, and its labeling also carries a warning for severe, potentially fatal gastrointestinal adverse events. Based on real-world evidence, use of SZC or patiromer has been associated with reduced medical costs and health care resource utilization, and some patients taking SZC or patiromer have been able to optimize doses of RAASi prescribed for other conditions. From a managed care perspective, proactive potassium control through routine use of potassium binders in patients with hyperkalemia may offer a means to reduce costly acute care while simultaneously supporting optimization of medications for comorbid conditions.