Hospital Pharmacy - June 2019 - 197

779012
research-article2018

HPXXXX10.1177/0018578718779012Hospital PharmacyJacob et al

Original Article

Hypoglycemia Associated With Insulin
Use During Treatment of Hyperkalemia
Among Emergency Department Patients

Hospital Pharmacy
2019, Vol. 54(3) 197-202
© The Author(s) 2018
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https://doi.org/10.1177/0018578718779012
DOI: 10.1177/0018578718779012
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Bobby C. Jacob1, Samuel K. Peasah1, Hannah L. Chan2, Dora
Niculas3, and Angela Shogbon Nwaesei1

Abstract
Purpose: Hypoglycemia is a common adverse event associated with insulin during treatment of hyperkalemia in hospitalized
patients; however, limited data exist regarding hypoglycemia incidence and appropriate dosing strategies for treatment of
patients in the emergency department. The study objective was to determine the incidence of hypoglycemia associated with
insulin use during treatment of hyperkalemia among patients seen in the emergency department. Methods: This was an
Institutional Review Board (IRB)-approved retrospective, chart-review study. All adult patients who received intravenous
regular insulin as a result of an order from the emergency department hyperkalemia order set were eligible for inclusion.
The main clinical outcomes were incidence of hypoglycemia (blood glucose <70 mg/dL) and severe hypoglycemia (blood
glucose <40 mg/dL). Blood glucose was checked within 24 hours of insulin administration. Results: A total of 172 patients
were included. The incidence of hypoglycemia was 19.8% (n = 34) and the incidence of severe hypoglycemia was 5.2% (n =
9). Hypoglycemic patients had a significantly lower median blood glucose at baseline compared to those who did not develop
hypoglycemia (83.5 [72.0-112.0] mg/dL vs 123.0 [96.0-167.0] mg/dL, P < .0001); however, no difference was noted between
groups in the average insulin dose administered (0.11 ± 0.04 units/kg vs 0.12 ± 0.05 units/kg, P = .6175). Conclusion:
There is a concerning risk of hypoglycemia associated with insulin use during treatment of hyperkalemia in the emergency
department. Standard insulin doses may not be appropriate in some cases like patients with lower baseline blood glucose.
Further research is warranted to develop safer hyperkalemia treatment protocols that mitigate this high risk of hypoglycemia
associated with insulin use.
Keywords
hypoglycemia, insulin, hyperkalemia, emergency department

Introduction
Hyperkalemia is a common electrolyte disorder that can
cause clinically significant adverse outcomes including cardiac arrhythmia leading to death.1 A variety of factors
including renal insufficiency, aldosterone insufficiency, and
medication use have been associated with an increased risk
of hyperkalemia.2,3 In 2014, approximately 141 million
patients visited emergency departments in the United
States.4 Epidemiological studies estimate that 2.6% to 3.5%
of emergency department visits and the resulting hospital
admissions arise from hyperkalemia; however, these figures
may underestimate the problem.5 Clinicians initiate treatments for hyperkalemia based on varying serum potassium
thresholds and certainly when patients display serious signs
and symptoms associated with hyperkalemia including
abnormal electrocardiographic changes. Treatment options
include protection of myocardial tissue with intravenously

administered calcium, promotion of intra-cellular shifting of
potassium with insulin, albuterol, or sodium bicarbonate in
the setting of metabolic acidosis, and removal of potassium
from the body with ion-exchange agents, loop diuretics, or
hemodialysis.2,6 Intravenously administered regular insulin
is a commonly used early treatment. The primary adverse
event associated with insulin in this setting is hypoglycemia,
which is particularly concerning given the evidence linking
hypoglycemia to poor clinical outcomes.7-10

1

Mercer University, Atlanta, GA, USA
University of Alabama at Birmingham Hospital, Birmingham, AL, USA
3
DeKalb Medical Center, Decatur, GA, USA
2

Corresponding Author:
Bobby C. Jacob, College of Pharmacy, Mercer University, 3001 Mercer
University Drive, Atlanta, GA 30341, USA.
Email: Jacob_bc@mercer.edu
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Hospital Pharmacy - June 2019

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