An international multidisciplinary consensus guideline from the Emergency Medicine Cardiac Research and Education Group (EMCREG) on the management of hyperkalemia in chronic kidney disease and heart failure notes that the primary focus of emergency department (ED) management of hyperkalemia is the prevention of cardiac complications of hyperkalemia. In addition to promoting potassium shift from the extracellular to intracellular fluid space, it is necessary to increase urinary or gastrointestinal (GI) potassium excretion. Gastrointestinal excretion can be promoted via oral binders such as patiromer and sodium zirconium cyclosilicate (SZC). However, these agents require a functioning GI tract and have a delayed onset of action; they should not be relied on to emergently reduce potassium in patients with arrhythmias. The guidelines note that SZC likely provides the more rapid and safest benefit as it binds potassium in the small bowel, while patiromer acts only in the colon. The recommended dose of patiromer for moderate hyperkalemia (5.6 to 5.9 mmol/L) is 8.4 g once daily or 8.4 g once daily titrated to a maximum dose of 25.2 g daily, until serum potassium is <5.1 mmol/L. Dosing recommendations for patiromer in severe hyperkalemia are not provided. [1]
An expert panel review published in 2025 on hyperkalemia management states that novel oral potassium binders can be used to help eliminate excess serum potassium in the setting of acute hyperkalemia. However, the definitive efficacy of potassium binders in acute hyperkalemia is still being investigated, and formal studies on patiromer in the emergency setting have been lacking. Despite the lack of data, a pilot investigation targeting severe and acute hyperkalemia patients revealed that a single oral dose of 25.2 g of patiromer led to a statistically significant reduction in serum potassium within 2 hours, indicating a potential role in acute hyperkalemia management (see Table 1). Similarly, another retrospective cohort study evaluating patiromer therapy for hyperkalemia in an acute care setting observed a mean potassium reduction of 0.50 mmol/L (p<0.001) within 0 to 6 hours following a single dose of patiromer administration (see Table 2). [2], [3], [4]
A 2021 systematic review and meta-analysis evaluated the safety and side effect profile of two novel agents, patiromer and SZC, for the treatment of hyperkalemia. The analysis incorporated data from a comprehensive search of electronic databases, including PubMed, Scopus, and Embase, focusing on studies that compared these agents with placebo or other standard care options. The odds ratio (OR) was utilized for outcome estimation, allowing the authors to quantify differences in hyperkalemia incidence and adverse effect occurrence between the treatment and control groups. The results demonstrated that patiromer significantly reduced hyperkalemia rates compared to standard care, with an OR of 0.44 (95% confidence interval [CI] 0.22 to 0.89), indicating a promising therapeutic profile for patients with chronic hyperkalemia. Conversely, while SZC showed no significant differences in hyperkalemia incidence during treatment, it was associated with a higher incidence of edema, likely due to increased sodium absorption. This finding is particularly relevant for patients with concurrent conditions like chronic kidney disease or heart failure. Conclusions of the review indicate SZC may be preferable for acute hyperkalemia due to its rapid potassium-lowering effects, whereas patiromer, with its favorable safety profile and lower risk of edema, may be more suitable for chronic management. The study emphasizes the importance of individualized treatment decisions based on patient-specific factors and the safety profiles of these agents. [5]