Hypoglycaemia often occurs in insulin-treated hyperkalemia patients

The use of intravenous (IV) insulin for managing hyperkalemia in hospitalized patients may lead to hypoglycaemia, which occurs more frequently in those with kidney-related conditions, according to a Singapore study.

“Early monitoring within the first 2 h after treatment is critical, as most hypoglycaemic events occur during this period,” the researchers said. 

“Intensive blood glucose monitoring and standardized treatment protocols based on patient risk factors, such as renal history, are essential to enhance patient safety and minimize hypoglycaemia,” they added.

Overall, 300 hospitalized patients between November 2020 and July 2022, who received IV insulin to treat acute hyperkalemia (serum potassium >5.0 to 5.5 mEq/L), were included in this prospective study. Blood glucose monitoring was done 1, 2, 4, and 6 h post-treatment.

Of the patients, 19.7 percent developed hypoglycaemia, with 78.6 percent of hypoglycaemic events occurring within the first 2 h, 12.9 percent at 4 h, and 8.6 percent at 6 h after treatment. [Proc Singap Healthc 2025;doi:10.1177/20101058251335693]

Notably, a history of kidney-related conditions, such as chronic kidney disease, and undergoing haemodialysis or peritoneal dialysis, significantly correlated with a higher risk of hypoglycaemia.

Among patients treated for hyperkalemia, 133 (44.4 percent) had persistent uncorrected serum potassium readings, and 29 (21.6 percent) encountered hypoglycaemia episodes.

Despite uncorrected potassium levels, hypoglycaemia can occur due to the timing mismatch between the effects of insulin on glucose and potassium, delayed insulin clearance, insufficient glucose supplementation, or excessive insulin administration, according to the researchers. [Sci Rep 2020;10:22044-22049; Endocr Pract 2017;23:353-362]

“While correcting potassium is critical for managing hyperkalemia, proper management of blood glucose through intensive monitoring of patients with repeated IV insulin administration is important to prevent hypoglycaemia,” they said.

Older age

Most of the patients in the current study were older, consistent with literature. This suggests that individuals over the age of 60 are at greater risk for hypoglycaemia. However, in this analysis, age was not a significant risk factor. [J Emerg Nurs 2023;49:99-108; Am J Emerg Med 2020;38:598-602; J Hosp Med 2019;14:284-287]

This can be explained by several factors, such as the influence of treatment protocols and comorbidities, which warrants further investigation. [Sci Rep 2020;10:22044-22049]

“Older age is often considered a risk factor for hypoglycaemia due to factors such as deteriorating renal function affecting drug clearance, increased adverse drug interactions from polypharmacy, and reduced cognitive functioning, which may impair the ability to detect or respond to hypoglycaemic episodes,” the researchers said. [Am J Med 2014;127:S17-S24]

“Further research is needed to refine these protocols and assess their effectiveness across diverse patient populations and clinical settings,” they noted.

In the acute care setting, acute hyperkalemia is a common complication experienced by patients. In the absence of immediate treatment, this may result in cardiac arrhythmias. Additionally, patients may even develop severe muscle weakness and paralysis. [Pharmacol Res 2016;113:585-591; Am J Med Sci 2014;347:93-100]

“Treatment of hyperkalemia using intravenous insulin is commonly administered to lower the serum potassium rapidly; however, it may result in risk, including hypoglycaemia,” the researchers said. [Am J Emerg Med 2019;37:209-213; PLoS One 2017;12:e0172961]