Strategies and Opportunities to Enhance Pharmacists’ Role in Hyperkalemia Management

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Hyperkalemia management is an area in which pharmacists can have a significant impact, particularly in ensuring that guideline-directed medical therapy (GDMT) is maintained while addressing elevated potassium levels. During a recent Pharmacy Times Clinical Forum discussion, Craig Beavers, PharmD, FACC, FAHA, FCCP, BCCP, BCPSAQ Cardiology, CACP, vice president of professional services at Baptist Health Paducah in Kentucky, and a panel of pharmacists shared insights on the tools and strategies that may enhance the pharmacist’s role in hyperkalemia care while addressing barriers and opportunities for improvement.

Danielle Garcia, PharmD, BCPS, a clinical pharmacy manager in transitional care excellence at Montefiore Health System in Bronx, New York, highlighted the complexity of finding tools that are both effective and well received by providers. She noted that although best practice alerts (BPAs) may seem like an ideal solution, they often lead to alert fatigue among providers, diminishing their efficacy. For example, Garcia noted that providers are more likely to ignore BPAs or override them during a busy shift. Garcia emphasized that the success of interventions such as BPAs often depends on ensuring they do not overwhelm the clinical workflow.

Tania Ahuja, PharmD, FACC, BCCP, BCPS, CACP, assistant director of clinical pharmacy services at NYU Langone Health in New York, New York, pointed out that the lack of robust national guidelines complicates the management of hyperkalemia, leaving health care providers to rely on inconsistent recommendations. This gap underscores the need for standardized pathways and protocols that integrate hyperkalemia management into broader GDMT frameworks. Similarly, Katherine E. Di Palo, PharmD, MBA, MS, an assistant professor in the Department of Medicine at the Albert Einstein College of Medicine at the Montefiore Health System, expressed frustration with the lack of pharmacy-driven guidelines. Specifically, Di Palo noted that pharmacists should take the lead in developing hyperkalemia protocols tailored to pharmacotherapy.

“My key takeaways are that there’s power in numbers and when it comes to pharmacotherapy, we are the key opinion leaders and we are the subject matter experts here. So why are we using other people’s guidelines to figure out our algorithms, our pathways, and our protocols? It’s because we don’t have any of our own,” Di Palo said. “What would make sense to me as next steps and action items is for us to start to develop a compendium of tools [for] pharmacotherapy and clinical decision support and how we get to the right drugs if the laboratory can’t suggest what’s on the formulary.”

The discussion also explored the importance of incentivizing providers to adhere to GDMT. Garcia suggested that tying provider incentives to the prescription of GDMT could encourage the appropriate use of therapies rather than prematurely discontinuing agents such as renin-angiotensin system inhibitors due to mild hyperkalemia. Beavers elaborated on this point, sharing an example of a heart failure pathway implemented at Baptist Health Paducah. This pathway, developed collaboratively across multiple disciplines, includes decision points that require providers to justify deviations from the protocol, ensuring accountability and promoting adherence to evidence-based practices.

A consistent theme among the panelists was the importance of collaborative practice agreements (CPAs) and interdisciplinary protocols. Jenna Ingram, PharmD, BCACP, ambulatory clinical pharmacy manager in cardiology at Mount Sinai Health System in New York, New York, recognized an opportunity to incorporate hyperkalemia management into existing CPAs, ensuring pharmacists have a more defined role in addressing this condition. Similarly, Isha Rana, PharmD, associate director of ambulatory pharmacy at Mount Sinai Health System; Kaitlyn Pinkos, PharmD, BCCP, a cardiothoracic intensive care unit clinical pharmacy specialist at NewYork-Presbyterian; and Shanice Coriolan, PharmD, BCPS, BCACP, BC-ADM, an ambulatory care pharmacist at NewYork-Presbyterian in New York, advocated for protocols to extend from inpatient to outpatient settings, where hyperkalemia management is often less structured.

“I would say we don’t have a formal [policy] for outpatient. But I think it’s because the [policies are] hybrid and they’re [using] an inpatient/outpatient protocol,” Coriolan said. “We have [sodium zirconium cyclosilicate (Lokelma; AstraZeneca)] on formulary, so outpatient is sending [sodium zirconium cyclosilicate] because that’s what they’re used to sending, and it only gets flipped if we get something back from the insurance. But I would say a lot of it comes from just [doing] what they’re used to.”

Ingram also emphasized the need to share expertise with other health care professionals on the team when discussing the treatment for hyperkalemia, which can foster a more unified approach. “On the inpatient side, [treatment approach] really depends on the patient and what they’re coming in for as well as their baseline renal function. I think there’s no specific approach that we take, but we all discuss it and take everything into consideration to make the best decision for the patient. So if it’s mild hyperkalemia, we get a baseline of what their potassium [level] may be at home and see if we can just change it with some of the medications or consider giving [sodium zirconium cyclosilicate] if needed,” Ingram said. “But because in the intensive care unit we have closer monitoring, if we see any electrocardiogram changes or more moderate to severe hyperkalemia, then we can act on it more quickly than other scenarios.”

Rebecca Chu, PharmD, BCPS, clinical pharmacy specialist at Northwell Health in New York, discussed challenges related to medication formulary management, particularly in settings with varying insurance coverage and socioeconomic factors. She proposed expanding pharmacists’ authority to interchange medications within the same therapeutic class to streamline patient care and minimize delays.

“When you have a patient who needs [potassium binders] urgently, the burden of a prior authorization stands in the way more than it does for [long-term] therapy,” Chu said.

Di Palo also highlighted the importance of the appropriate use of hyperkalemia therapies to avoid unnecessary interventions, such as the overuse of potassium binders. “There was a study published at our institution that actually looked at potassium lowering in patiromer [Veltassa; Vifor Pharma, Inc] and also looked at the prescribing patterns, in terms of the thresholds for initiating a potassium binder as well as how quickly they would follow up,” Di Palo said. “Because you get the 5.5 [mEq/L], they throw in a binder. Some of them didn’t even check it. So that was an interesting thing for us.”

From the inpatient perspective, Juri Chung, PharmD, clinical pharmacy specialist at North Shore University Hospital in Manhasset, New York, and Abhishek Shah, PharmD, clinical pharmacy manager at Montefiore Medical Center, emphasized the role of education in optimizing hyperkalemia management. Chung noted that although order sets exist in many institutions, they are often underutilized due to workflow barriers or lack of awareness. Shah stressed the importance of proactive communication with providers to revisit decisions, such as discontinuing beneficial medications after a past episode of hyperkalemia.

Garcia and Di Palo also called for a broader focus on population health. Garcia suggested leveraging data to identify gaps in GDMT uptake and tailoring interventions to address systemic barriers. Di Palo reinforced the idea of creating pharmacist-led guidelines and decision-support tools, advocating for a more proactive approach to shaping hyperkalemia management.

As the discussion concluded, the panelists reflected on the need for creative solutions and pilot programs to address persistent challenges. Beavers underscored the value of data-driven initiatives to build consensus and foster collaboration among stakeholders. The session ended with a call to action for pharmacists to take ownership of hyperkalemia care by developing innovative models of care, advocating for policy changes, and leading efforts to standardize treatment pathways.

Overall, the pharmacist’s role in hyperkalemia care is multifaceted, requiring a balance of clinical expertise, collaboration, and innovation. By addressing barriers such as alert fatigue, inconsistent guidelines, and formulary restrictions, pharmacists can enhance patient outcomes and support the broader implementation of GDMT. With their unique position in the health care team, pharmacists are well equipped to lead efforts in advancing hyperkalemia management across inpatient and outpatient settings.