(953) Evaluation of Insulin Dosing Strategies for Hyperkalemia Management at an Academic Medical Center

Introduction: While intravenous (IV) insulin is often administered at a fixed dose of 10 units for acute hyperkalemia, no optimal dose that balances potassium reduction with hypoglycemia minimization has been established. The purpose of this analysis was to evaluate the safety and efficacy of different IV insulin dosing strategies in patients receiving insulin for hyperkalemia.

Methods: We retrospectively identified all adult patients presenting to an academic medical center who received IV insulin for hyperkalemia between 2016 and 2020. Patients treated with 10 units of insulin (fixed) were compared to those who received < 10 units (reduced). The primary outcome was the incidence of hypoglycemia (blood glucose < 70 mg/dL) within 12 hours of insulin administration. Secondary outcomes included the incidence of severe hypoglycemia (blood glucose < 40 mg/dL) and change in potassium. Multivariable analyses were used to assess for risk factors for hypoglycemia, including weight-based insulin dose, sex, serum creatinine, baseline glucose, dextrose dose, diabetes history, insulin use at baseline, standing subcutaneous insulin prior to IV insulin, and intensive care unit (ICU) or emergency department (ED) location.

Results: The cohort included 2,576 patients, of whom 305 (11.8%) received reduced dosing and 2,271 (88.2%) received fixed dosing. Hypoglycemia occurred in 16.7% of the reduced group and 15.9% of the fixed group (p = 0.70). Severe hypoglycemia occurred in 2.3% of the reduced group and 2.5% of the fixed group (p = 0.86). Potassium reduction from baseline to first check post-insulin administration was less with reduced dosing (-0.6 mEq/L vs. -0.8 mEq/L, p < 0.001). On multivariable regression analysis, higher weight-based insulin dose (OR 2.13, 95% CI 1.63-2.77) and location in the ED (OR 1.90, 95% CI 1.49-2.43) were significant predictors for hypoglycemia. Location in the ICU (OR 0.48, 95% CI 0.33-0.72) and higher baseline glucose (OR 0.99, 95% CI 0.99-0.99) were associated with a decreased risk.

Conclusions: The incidence of hypoglycemia was similar among both groups. Higher weight-based insulin dose was a significant risk factor for hypoglycemia, while higher baseline glucose levels were associated with a decreased risk, indicating that patient-specific insulin dosing for hyperkalemia may be warranted.