Hyperkalemia, treatment (not first-line): Limited data available: Note: Due to delayed onset of action, sodium polystyrene sulfonate should not be used an emergency treatment for life-threatening hyperkalemia. Generally, not recommended for use in premature neonates due to their GI hypomotility and subsequent risk of complications, including but not limited to NEC and hypernatremia; per manufacturer labeling, use is contraindicated in neonates with reduced gut motility.
Preterm and term neonates: Rectal: 1 g/kg/dose with a 15 to 30 minute retention every 4 to 6 hours in combination with other ongoing therapies to reduce serum K; monitor serum potassium frequently and discontinue resin therapy promptly when able (Ref); may employ lower doses by using the exchange ratio of 1 mEq K+/g of sodium polystyrene sulfonate resin as the basis for calculation. Note: Sorbitol-free formulation is preferred.
Pretreatment of formula or expressed breast milk; to decrease potassium load for renal failure patients: Limited data available; various approaches reported: Term neonates: Usual dose: ~1 g/100 mL of infant formula or expressed breast milk, adjust dose based on patient serum potassium trends; reported dose range: 0.4 to 1.5 g/100 mL (Ref). When using infant formula, some experts recommend using 1g/mEq K+ content of the formula (Ref). After addition of resin to formula/breast milk, shake vigorously to mix, allow to sit under refrigeration for 60 minutes, then decant liquid for infant feed and leave precipitate at the bottom. In addition to decreasing the potassium load of the feed (subsequently patient's serum K) (Ref), other electrolyte concentrations may also be decreased (eg, Ca, Mg, Cu, Zn) in the formulas and increases in sodium concentrations of the feed; patients should be monitored closely.
Hyperkalemia: Limited data available: Note: Typically not first-line; used when necessary to increase potassium excretion (Ref). Due to delayed onset of action, sodium polystyrene sulfonate should not be used an emergency treatment for life-threatening hyperkalemia.
Weight-based dosing: Infants, Children, and Adolescents:
Oral, nasogastric: 1 g/kg/dose every 6 hours; maximum dose: 15 g/dose; Note: Oral route more effective than rectal and is preferred (Ref)
Rectal: 1 g/kg/dose every 2 to 6 hours; maximum dose range: 30 to 50 g/dose; retain at least 15 to 60 minutes (Ref); Note: Sorbitol-free preparations are preferred (Ref)
Exchange-ratio based dosing: Infants and small children: Oral, nasogastric, rectal: 1 mEq K+/g of sodium polystyrene sulfonate resin as the basis for calculation.
Pretreatment of formula or expressed breast milk; decrease potassium load for renal failure patients: Limited data available; various approaches reported: Infants and Children:
Infant/Enteral formula: 0.5 to 2.6 g/100 mL of formula (Ref) or 0.25 to 1g/mEq K+ content of formula (Ref), adjust dose based on patient serum potassium trends. After addition of the resin, shake vigorously to mix, allow to sit under refrigeration for 30 to 60 minutes, then decant liquid for feed and leave precipitate at the bottom. The extent of potassium removal depends on the formula; in one trial, Similac PM 60/40 samples showed significant decreases at additive amounts of 0.25 to 1 g/mEq K+ content of formula versus Suplena which only showed significant reduction of K+ concentrations in the formula at 1 g/mEq K+ content of formula (Ref). Other electrolyte concentrations may also be decreased (eg, Ca, Mg, Cu, Zn) and significant increases in sodium concentrations of the formula were consistently reported; patients should be monitored closely.
Expressed breast milk: Usual dose: ~1 g/100 mL; adjust based on patient serum potassium trends; reported dose range: 0.4 to 1.5 g/100 mL of expressed breast milk. After addition of the resin, shake vigorously to mix, allow to sit under refrigeration for 60 minutes, then decant liquid for infant feed and leave precipitate at the bottom. In addition to decreasing the potassium load of the feed (subsequently patient's serum K) (Ref), other electrolyte concentrations may also be decreased (eg, Ca, Mg, Cu, Zn) and sodium concentrations (breast milk and serum) increased; patients should be monitored closely (Ref).
Dosage adjustment for concomitant therapy: Significant drug interactions exist, requiring dose/frequency adjustment or avoidance. Consult drug interactions database for more information.
There are no dosage adjustments provided in the manufacturer's labeling. Use with caution; risks of gastrointestinal adverse effects are greater in patients with renal insufficiency or failure.
There are no dosage adjustments provided in the manufacturer's labeling.
(For additional information see "Sodium polystyrene sulfonate: Drug information")
Hyperkalemia, chronic:
Note: Use has been associated with an increased risk of GI adverse events, including intestinal necrosis, especially when administered with sorbitol; concomitant administration of sorbitol is not recommended. Prior to use, carefully assess risk versus benefit of therapy and consider alternative agents (eg, patiromer, sodium zirconium cyclosilicate) when feasible (Ref). Avoid use (with or without sorbitol) in patients with risk factors for constipation or impaction (eg, history of impaction, chronic constipation, previous bowel surgery, inflammatory bowel disease); discontinue use if constipation occurs.
Oral: 15 g 1 to 4 times daily.
Rectal: 30 to 50 g every 6 hours.
Hyperkalemia , severe/emergent (alternative agent) (off-label use):
Note: Due to rare but significant complications, including intestinal necrosis (with or without sorbitol use), strongly consider other therapies for elimination of potassium, unless the patient meets ALL of the following criteria: Patient has potentially life-threatening hyperkalemia; dialysis is not readily available; newer cation exchangers (eg, sodium zirconium cyclosilicate) are not available; other therapies to eliminate potassium from body have failed or are not possible (eg, diuretics, rapid restoration of kidney function) (Ref). Safety: Do not administer (with or without sorbitol) to the following patients due to the potential increased risk of intestinal necrosis: Postoperative patients, patients with an ileus, patients with constipation or at risk of becoming constipated (eg, due to opioid use), patients with a large or small bowel obstruction, patients with underlying bowel disease (eg, ulcerative colitis, Clostridioides difficile colitis) (Ref).
Oral (preferred route): 15 to 30 g once; may repeat up to 4 times per day as needed based upon serum potassium levels. Maximum daily dose: 60 g/day (Ref).
Rectal retention enema: 30 to 50 g every 2 to 6 hours, as needed, based upon serum potassium levels (Ref). Note: Concomitant administration of sorbitol is not recommended.
Dosage adjustment for concomitant therapy: Significant drug interactions exist, requiring dose/frequency adjustment or avoidance. Consult drug interactions database for more information.
The renal dosing recommendations are based upon the best available evidence and clinical expertise. Senior Editorial Team: Bruce Mueller, PharmD, FCCP, FASN, FNKF; Jason Roberts, PhD, BPharm (Hons), B App Sc, FSHP, FISAC; Michael Heung, MD, MS.
Altered kidney function: No dosage adjustment necessary for any degree of kidney dysfunction (not systemically absorbed) (Ref).
Hemodialysis, intermittent (thrice weekly): Unlikely to be dialyzed: No supplemental dose or dosage adjustment necessary (not systemically absorbed) (Ref).
Peritoneal dialysis: Unlikely to be dialyzed: No dosage adjustment necessary (not systemically absorbed) (Ref).
CRRT: No dosage adjustment necessary (not systemically absorbed) (Ref).
PIRRT (eg, sustained, low-efficiency diafiltration): No dosage adjustment necessary (not systemically absorbed) (Ref).
There are no dosage adjustments provided in the manufacturer's labeling.
The following adverse drug reactions are derived from product labeling unless otherwise specified.
Postmarketing:
Endocrine & metabolic: Alkalosis (Kakajiwala 2017), hypernatremia (Angel-Korman 2022), hypocalcemia (Kakajiwala 2017), hypokalemia (Angel-Korman 2022), hypomagnesemia, sodium retention
Gastrointestinal: Anorexia, bezoar formation (Croitoru 2015), colitis (Dos Santos 2021), constipation, diarrhea (Nepal 2010), fecal impaction, gastric irritation, gastrointestinal hemorrhage (Dantas 2021), gastrointestinal necrosis (including esophageal necrosis, intestinal necrosis) (Almulhim 2018, Garcia Rodriguez 2020, Klasen 2021), gastrointestinal perforation (Faucon 2018, Piron 2018), gastrointestinal ulcer (Albeldawi 2014), intestinal obstruction, ischemic colitis (Edhi 2018), nausea, vomiting
Nervous system: Foreign body reaction (Zaidan 2013)
Hypersensitivity to sodium polystyrene sulfonate, polystyrene sulfonate resins or any component of the formulation; hypokalemia (excluding Kayexalate); obstructive bowel disease; neonates with reduced gut motility; oral administration in neonates; rectal administration in neonates (sorbitol-containing formulations only)
Concerns related to adverse effects:
• Aspiration: Acute bronchitis and bronchopneumonia caused by inhalation of sodium polystyrene sulfonate particles have been reported; patients with impaired gag reflex, altered level of consciousness or patients prone to regurgitation may be at increased risk. Administer with the patient in an upright position.
• Electrolyte disturbances: Severe hypokalemia may occur; frequent monitoring of serum potassium is recommended within each 24-hour period; ECG monitoring may be appropriate in select patients. Cation-exchange resins may also affect other cation concentrations, possibly resulting in decreased serum magnesium and calcium.
• Fecal impaction: Large oral doses may cause fecal impaction (especially in elderly); rectal administration has been associated with fecal impaction in children.
• Intestinal necrosis: Intestinal necrosis (including fatalities) and other serious gastrointestinal events (eg, bleeding, ischemic colitis, perforation) have been reported, especially when administered with sorbitol; concomitant administration of sorbitol is not recommended. Increased risk may be associated with a history of intestinal disease or surgery, hypovolemia, prematurity, and renal insufficiency or failure. Strongly consider other therapies for elimination of potassium, unless the patient meets ALL of the following criteria: Patient has potentially life-threatening hyperkalemia; dialysis is not readily available; newer cation exchangers are not available; other therapies to eliminate potassium from body have failed or are not possible (eg, diuretics, rapid restoration of kidney function) (Mount 2022; Parks 2019). Do not administer (with or without sorbitol) to the following patients due to the potential increased risk of intestinal necrosis: Postoperative patients; patients with an ileus; patients with constipation or at risk of becoming constipated (eg, due to opioid use); patients with a large or small bowl obstruction; patients with underlying bowel disease (eg, ulcerative colitis, Clostridioides difficile colitis) (Mount 2022; Parks 2019).
Disease-related concerns:
• Cardiovascular disease: Use with caution in patients with severe heart failure and/or hypertension; sodium load may exacerbate condition.
• Edema: Use with caution in patients with edema; sodium load may exacerbate condition.
• Renal impairment: Use with caution in patients with kidney impairment; risks of GI adverse effects are greater in patients with kidney impairment or failure.
Special populations:
• Older adults: Higher doses in older adults may result in fecal impaction.
• Pediatric: Oral administration in neonates and use in neonates with reduced gut motility (postoperatively or drug-induced) is contraindicated. Rectal administration of sorbitol-containing formulations in neonates is also contraindicated. Use with caution in premature or low-birth-weight infants. Use with caution in children when administering rectally; excessive dosage or inadequate dilution may result in fecal impaction.
Dosage form specific issues:
• Propylene glycol: Some dosage forms may contain propylene glycol; large amounts are potentially toxic and have been associated hyperosmolality, lactic acidosis, seizures, and respiratory depression; use caution (AAP 1997; Zar 2007).
Other warnings/precautions:
• Appropriate use: Effective lowering of serum potassium from sodium polystyrene sulfonate may take hours to days after administration; consider alternative measures (eg, dialysis) or concomitant therapy (eg, IV sodium bicarbonate) in situations where rapid correction of severe hyperkalemia is required.
• Enema vs oral administration: Enema will reduce the serum potassium faster than oral administration, but the oral route will result in a greater reduction over several hours.
Some dosage forms may contain propylene glycol; in neonates large amounts of propylene glycol delivered orally, intravenously (eg, >3,000 mg/day), or topically have been associated with potentially fatal toxicities which can include metabolic acidosis, seizures, renal failure, and CNS depression; toxicities have also been reported in children and adults including hyperosmolality, lactic acidosis, seizures, and respiratory depression; use caution (AAP 1997; Shehab 2009).
Excipient information presented when available (limited, particularly for generics); consult specific product labeling. [DSC] = Discontinued product
Powder, Oral:
Kalexate: (454 g [DSC]) [sorbitol free; contains sodium 100 mg (4.1 mEq)/g]
Kayexalate: (453.6 g [DSC]) [contains sodium 100 mg (4.1 mEq)/g]
Kionex: (454 g [DSC]) [contains sodium 100 mg (4.1 mEq)/g]
Generic: (15 g, 453.6 g, 454 g)
Suspension, Oral:
Kionex: 15 g/60 mL (60 mL [DSC], 473 mL [DSC]) [contains alcohol, usp, methylparaben, propylene glycol, propylparaben, saccharin sodium, sodium 1500 mg (65 mEq)/60 mL, sorbitol; raspberry flavor]
SPS: 15 g/60 mL (60 mL, 120 mL, 473 mL) [contains alcohol, usp, methylparaben, propylene glycol, propylparaben, saccharin sodium, sodium 1500 mg (65 mEq)/60 mL, sorbitol; cherry flavor]
Generic: 15 g/60 mL (60 mL, 480 mL, 500 mL)
Suspension, Rectal:
Generic: 30 g/120 mL (120 mL [DSC]); 50 g/200 mL (200 mL [DSC])
Yes
Suspension (SPS Oral)
15 g/60 mL (per mL): $1.21
Disclaimer: A representative AWP (Average Wholesale Price) price or price range is provided as reference price only. A range is provided when more than one manufacturer's AWP price is available and uses the low and high price reported by the manufacturers to determine the range. The pricing data should be used for benchmarking purposes only, and as such should not be used alone to set or adjudicate any prices for reimbursement or purchasing functions or considered to be an exact price for a single product and/or manufacturer. Medi-Span expressly disclaims all warranties of any kind or nature, whether express or implied, and assumes no liability with respect to accuracy of price or price range data published in its solutions. In no event shall Medi-Span be liable for special, indirect, incidental, or consequential damages arising from use of price or price range data. Pricing data is updated monthly.
1 g of resin binds ∼1 mEq of potassium; 4.1 mEq sodium per g of powder; 1 level teaspoon contains 3.5 g polystyrene sulfonate
Oral or NG: Administer orally or via NG tube with patient in an upright position at least 3 hours before or 3 hours after other medications (patients with gastroparesis may require a 6 hour separation). Do not mix in orange juice or any fruit juice known to contain potassium.
Oral suspension: Shake commercially available suspension well before use.Chilling the oral mixture will increase palatability.
Powder for suspension: Powdered resin must be mixed with water or syrup prior to administration.
Rectal: Route is less effective than oral administration. Administer cleansing enema first. Each dose of the powder for suspension should be suspended in an aqueous vehicle and administered as a warm emulsion (body temperature). The commercially available suspension should also be warmed to body temperature. During administration, the solution should be agitated gently. Retain enema in colon: Neonates: 30 minutes; in older patients: At least 30 to 60 minutes and for several hours, if possible. Once retention time is complete, irrigate colon with a nonsodium-containing solution to remove resin.
Oral or NG: Administer orally or via NG tube with patient in an upright position at least 3 hours before or 3 hours after other medications (patients with gastroparesis may require a 6 hour separation). Do not mix in orange juice or in any fruit juice known to contain potassium. Shake the suspension well prior to administration. Chilling the oral mixture will increase palatability. Sodium polystyrene sulfonate suspension may also be added to the patient's food (with the exception of potassium-containing food such as bananas and orange juice).
Rectal: Administer cleansing enema first. Administer sodium polystyrene sulfonate as a warm emulsion (body temperature). During administration, the solution should be agitated gently. Retain the enema in the colon for at least 30 to 60 minutes and for several hours, if possible. Once retention time is complete, irrigate the colon with a nonsodium-containing solution to remove resin.
Store at 25°C (77°F); excursions permitted to 15°C to 30°C (59°F to 86°F). Store repackaged product in refrigerator and use within 14 days. Freshly prepared suspensions should be used within 24 hours. Do not heat resin suspension.
Treatment of hyperkalemia (FDA approved in pediatric patients [age not specified] and adults); has also been used as pretreatment of infant formulas/expressed breast milk to lower the potassium load for renal failure patients (acute and chronic)
Kayexalate [DSC] may be confused with Kaopectate, Kay Ciel
Sodium polystyrene sulfonate may be confused with calcium polystyrene sulfonate
KIDs List: Sodium polystyrene sulfonate, when used in very low birthweight neonates, is identified on the Key Potentially Inappropriate Drugs in Pediatrics (KIDs) list and should be avoided due to risk of colonic perforation (weak recommendation; low quality of evidence) (PPA [Meyers 2020]).
Always prescribe either one-time doses or as a specific number of doses (eg, 15 g q6h x 2 doses). Scheduled doses with no dosage limit could be given for days leading to dangerous hypokalemia.
Kionex [US] may be confused with Kinex brand name for biperiden [Mexico]
None known.
Note: Interacting drugs may not be individually listed below if they are part of a group interaction (eg, individual drugs within “CYP3A4 Inducers [Strong]” are NOT listed). For a complete list of drug interactions by individual drug name and detailed management recommendations, use the drug interactions program by clicking on the “Launch drug interactions program” link above.
Note: Interacting drugs may not be individually listed below if they are part of a group interaction (eg, individual drugs within “CYP3A4 Inducers [Strong]” are NOT listed). For a complete list of drug interactions by individual drug name and detailed management recommendations, use the drug interactions program
Antacids: May enhance the adverse/toxic effect of Sodium Polystyrene Sulfonate. Specifically, the risk of metabolic alkalosis may be increased. Antacids may diminish the therapeutic effect of Sodium Polystyrene Sulfonate. Risk C: Monitor therapy
Laxatives (Magnesium Containing): May enhance the adverse/toxic effect of Sodium Polystyrene Sulfonate. More specifically, concomitant use of sodium polystyrene sulfonate with magnesium-containing laxatives may result in metabolic alkalosis or with sorbitol may result in intestinal necrosis. Management: Avoid concomitant use of sodium polystyrene sulfonate (rectal or oral) and magnesium-containing laxatives. Risk X: Avoid combination
Lithium: Sodium Polystyrene Sulfonate may decrease the serum concentration of Lithium. Management: To minimize the risk for interaction, separate dosing of oral sodium polystyrene sulfonate (SPS) and lithium by administering lithium at least 3 hours before or at least 3 hours after SPS. Consider a 6 hour dose separation in patients with gastroparesis. Risk D: Consider therapy modification
Meloxicam: May enhance the adverse/toxic effect of Sodium Polystyrene Sulfonate. More specifically, concomitant use of meloxicam oral suspension (which contains sorbitol) may increase the risk for intestinal necrosis. Risk X: Avoid combination
Sorbitol: May enhance the adverse/toxic effect of Sodium Polystyrene Sulfonate. More specifically, concomitant use of these agents may increase the risk for intestinal necrosis. Risk X: Avoid combination
Tenapanor: Sodium Polystyrene Sulfonate may diminish the therapeutic effect of Tenapanor. Management: Separate administration of tenapanor and sodium polystyrene sulfonate (SPS) by at least 3 hours. Risk D: Consider therapy modification
Thyroid Products: Sodium Polystyrene Sulfonate may decrease the serum concentration of Thyroid Products. Management: Consider administering thyroid products at least 4 hours prior to sodium polystyrene sulfonate. Monitor for signs and symptoms of hypothyroidism with concomitant use. Risk D: Consider therapy modification
Some liquids may contain potassium: Management: Do not mix in orange juice or in any fruit juice known to contain potassium.
Do not mix in orange juice or in any fruit juice known to contain potassium. Some products may contain sodium.
Animal reproduction studies have not been conducted. Sodium polystyrene sulfonate is not absorbed systemically following oral or rectal administration. Use during pregnancy is not expected to result in significant exposure to the fetus.
Serum sodium, potassium, calcium, magnesium, ECG, and acid/base status (if applicable)
Removes potassium by exchanging sodium ions for potassium ions in the intestine (especially the large intestine) before the resin is passed from the body; the practical exchange capacity is 1 mEq potassium per 1 g of resin in vivo, and in vitro capacity is 3.1 mEq of potassium per 1 g of resin, therefore, a wide range of exchange capacity exists such that close monitoring of serum electrolytes is necessary.
Onset of action: Hours to days
Absorption: None
Excretion: Completely feces (primarily as potassium polystyrene sulfonate)
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