Note: Each gram of resin can potentially bind up to 0.5 to 1 mEq of potassium (Ref).
Hyperkalemia, treatment: Note: Due to delayed onset of action, exchange resins should not be used as emergency treatment for life-threatening hyperkalemia (Ref). Use is contraindicated in neonates with reduced gut motility (manufacturer's labeling); generally not recommended in neonates due to low efficacy and increased risk of complications (Ref).
Neonates: Rectal: 0.5 to 1 g/kg/day in divided doses every 6 to 8 hours as needed (Ref); doses as high as 1 g/kg/dose every 6 hours have also been reported (Ref). Once retention time is complete, irrigate colon with NS to remove resin and prevent impaction (Ref).
Note: Each gram of resin can potentially bind up to 0.5 to 1 mEq of potassium (Ref).
Hyperkalemia: Due to delayed onset of action, exchange resins should not be used as emergency treatment for life-threatening hyperkalemia (Ref).
Infants, Children, and Adolescents:
Oral: 0.5 to 1 g/kg/day in divided doses every 6 to 8 hours as needed; maximum dose: 15 g/dose (Ref); doses as high as 1 g/kg/dose have been reported (Ref).
Rectal: 0.5 to 1 g/kg/day in divided doses every 6 to 8 hours as needed; maximum dose: 30 g/dose (Ref); doses as high as 1 g/kg/dose have been reported (Ref). Once retention time is complete, irrigate the colon to ensure adequate removal of the resin (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 specific dosage adjustments provided in the manufacturer's labeling; however, dosage adjustments may be necessary based on changes in serum potassium and/or calcium levels.
There are no dosage adjustments provided in the manufacturer's labeling.
(For additional information see "Calcium polystyrene sulfonate (United States: Not available): Drug information")
Note: Each gram of resin has a theoretical in vitro exchange capacity of about 1.3 to 2 mmol (1.3 to 2 mEq) of potassium. In vivo, the actual amount of potassium bound will be less than this.
Hyperkalemia, nonemergent: Note: Initiate treatment if serum potassium level >6 mmol/L (6 mEq/L); discontinue when serum potassium level ≤5 mmol/L (5 mEq/L).
Oral: Usual dose: 15 g 3 to 4 times daily; dose based on clinical presentation and serum potassium level.
Rectal enema: 30 g once daily.
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 specific dosage adjustments provided in the manufacturer's labeling; however, dosage adjustments may be necessary based on changes in serum potassium and/or calcium levels.
There are no dosage adjustments provided in the manufacturer's labeling
The following adverse drug reactions and incidences are derived from product labeling unless otherwise specified.
Frequency not defined: Gastrointestinal: Anorexia, constipation, diarrhea, gastric irritation, nausea, vomiting
Postmarketing:
Endocrine & metabolic: Hypercalcemia (Arroyo 2012), hypomagnesemia
Gastrointestinal: Abdominal distention (Kao 2015), abdominal pain (Kao 2015), bezoar formation (oral administration) (Fiel 2019), fecal impaction (Fiel 2019), gastrointestinal necrosis (Joo 2009; Kao 2015), gastrointestinal stenosis, gastrointestinal ulcer (Fung 2020), ileitis (including ulcerative ileocolitis) (Mansour 2021), intestinal obstruction (Fung 2020; Kao 2015), ischemic colitis, mesenteric ischemia, peritonitis, rectal hemorrhage
Hypersensitivity to polystyrene sulfonate resins or any component of the formulation; potassium <5 mmol/L (5 mEq/L); conditions associated with hypercalcemia (eg, metastatic carcinoma, multiple myeloma, hyperparathyroidism, or sarcoidosis); obstructive bowel disease; oral administration in neonates; use in neonates with reduced gut motility (postoperative, drug induced)
Concerns related to adverse effects:
• Electrolyte disturbances: Use may be associated with electrolyte disturbances including hypokalemia, hypercalcemia, and/or hypomagnesemia. Closely monitor electrolytes during therapy. Discontinue use if potassium ≤5 mmol/L (5 mEq/L).
• GI effects: Gastrointestinal stenosis, intestinal ischemia, ischemic colitis, rectal hemorrhage, gastrointestinal necrosis, and intestinal perforation with fatal outcomes have been reported, particularly in patients with underlying risk factors (eg, prematurity, history of intestinal disease or surgery, renal impairment, hypovolemia, severe burn, immunosuppressive therapy). Fecal impaction with rectal administration and concretion formation with oral administration have also occurred. Effects may be related to use of sorbitol enema with inadequate/absence of lavage after resin use. Avoid excess dosing or inadequate dilution with rectal administration to avoid resin impaction. Discontinue use in patients with clinically significant constipation. Intermittent therapy may be considered for patients developing nausea/vomiting, diarrhea, gastric irritation and anorexia, and the use of mild laxatives may be considered if constipation occurs.
Disease-related concerns:
• Renal impairment: Use with caution in renal impairment and/or dialysis patients. Sudden increases in calcium may be observed; monitor calcium weekly (or more frequently if clinically indicated). Dosage adjustments may be necessary.
Special populations:
• Neonates/infants: Oral administration is contraindicated in neonates. Use caution with rectal administration to avoid resin impaction. Premature/low-birth-weight infants may be at risk for GI hemorrhage or colonic necrosis.
Not available in the US
Excipient information presented when available (limited, particularly for generics); consult specific product labeling.
Powder for suspension, oral/rectal:
Resonium Calcium: 300 g [contains calcium 1.6 to 2.4 mmol/g, sodium <1 mg/g; packaging contains 15 g measuring device]
Each 1 g of resin contains 1.6 to 2.4 mmol of calcium and <1 mg of sodium.
Note: Plastic spoon provided with jar measures 15 g of powdered resin when level.
Oral: Infants, Children, and Adolescents:
Administer orally (or via gastric tube if unable to swallow) as a suspension or paste prepared with honey, jam, water, or other liquids with low potassium content. Patients should be positioned carefully during ingestion to avoid aspiration. Note: Oral administration in neonates is contraindicated.
Rectal: Rectal route is less effective than oral administration. Administer rectally as a prepared suspension; enema should be retained as long as possible, as greater amounts of potassium are excreted as retention time increases; recommended retention times: Neonates: At least 30 minutes (Ref); Infants, Children, and Adolescents: At least 30 to 60 minutes (Ref). Once retention time is complete, irrigate colon with NS to remove resin and prevent impaction (Ref).
Oral: Administer orally (via nasogastric tube if unable to swallow) at least 3 hours before or 3 hours after other oral medications (patients with gastroparesis may require a 6 hour separation) as a prepared suspension or paste. Patient should be positioned carefully during ingestion to avoid aspiration. Note: More rapid lowering of potassium may be achieved with concomitant oral and rectal administration. Rectal route may be discontinued once orally administered resin has reached rectum.
Rectal: Enema route is less effective than oral administration. Administer rectally as a prepared suspension.
Enema should be retained as long as possible (product labeling suggests for at least 9 hours in adults or as long as possible) as greater amounts of potassium are excreted as retention time increases. Follow enema with irrigation to remove resin. Note: More rapid lowering of potassium may be achieved with concomitant oral and rectal administration. Rectal route may be discontinued once orally administered resin has reached rectum.
Store between 15°C to 30°C (59°F to 86°F).
Note: Not approved in the United States.
Resonium calcium [Canadian product]: Treatment of hyperkalemia (indicated in all ages).
Calcium polystyrene sulfonate may be confused with sodium polystyrene sulfonate
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
Aluminum Hydroxide: Calcium Polystyrene Sulfonate may enhance the adverse/toxic effect of Aluminum Hydroxide. More specifically, concomitant use of these agents may increase the risk for intestinal obstruction. Management: Monitor for signs/symptoms of intestinal obstruction with concomitant use of calcium polystyrene sulfonate and aluminum hydroxide. Adequate fluid intake, laxative use, alternative antacid agents, and/or limiting duration of therapy may help reduce risks. Risk D: Consider therapy modification
Antacids: May enhance the adverse/toxic effect of Calcium Polystyrene Sulfonate. The combined use of these two agents may result in metabolic alkalosis. Risk C: Monitor therapy
Cardiac Glycosides: Calcium Polystyrene Sulfonate may enhance the adverse/toxic effect of Cardiac Glycosides. Specifically, the risk for increased digoxin toxicity may occur if hypokalemia is present. Risk C: Monitor therapy
Laxatives (Magnesium Containing): May enhance the adverse/toxic effect of Calcium Polystyrene Sulfonate. More specifically, concomitant use of calcium polystyrene sulfonate with magnesium-containing laxatives may result in metabolic alkalosis or with sorbitol may result in intestinal necrosis. Management: Avoid concomitant use of calcium polystyrene sulfonate (rectal or oral) and magnesium-containing laxatives. Risk X: Avoid combination
Lithium: Calcium Polystyrene Sulfonate may decrease the serum concentration of Lithium. Management: To minimize the risk for interaction, separate dosing of oral CPS and lithium by administering lithium at least 3 hours before or at least 3 hours after CPS. Consider a 6 hour dose separation in patients with gastroparesis. Risk D: Consider therapy modification
Meloxicam: May enhance the adverse/toxic effect of Calcium 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 Calcium Polystyrene Sulfonate. More specifically, concomitant use of these agents may increase the risk for intestinal necrosis. Risk X: Avoid combination
Thyroid Products: Calcium Polystyrene Sulfonate may decrease the serum concentration of Thyroid Products. Management: Consider administering thyroid products at least 4 hours prior to calcium polystyrene sulfonate. Monitor for signs and symptoms of hypothyroidism with concomitant use. Risk D: Consider therapy modification
May administer orally with honey, jam, or liquids with low potassium content. Do not mix in fruit juices (eg, orange juice) or other beverages with high potassium content. Some products may contain sodium.
Calcium polystyrene sulfonate does not undergo gastrointestinal (GI) absorption. In general, medications used as antidotes should take into consideration the health and prognosis of the mother; antidotes should be administered to pregnant women if there is a clear indication for use and should not be withheld because of fears of teratogenicity (Bailey 2003).
Monitor serum electrolytes (potassium, sodium, calcium, magnesium); monitor for constipation; monitor for GI hemorrhage or gastric necrosis in neonates and infants.
Removes potassium by exchanging calcium ions for potassium ions in the intestine before the resin is excreted from the body
Onset of action: May be delayed 1 to 2 days due to GI transit time
Absorption: None
Excretion: Feces (100%)
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