POTASSIUM BINDING AGENTS IN THE INTENSIVE CARE UNIT: A NARRATIVE REVIEW

Bodhisattwa B., Akshat S., Nikhilesh J.*

Hyperkalemia is a frequently encountered and potentially life-threatening electrolyte disturbance in critically ill patients, with reported prevalence rates of 20–40% in the intensive care unit (ICU) setting. While emergent stabilization with intravenous calcium gluconate, insulin-dextrose, and bicarbonate remains the cornerstone of acute management achieving sustained reduction in serum potassium requires the adjunctive use of potassium binding agents (PBAs). Historically, sodium polystyrene sulfonate (SPS) was the only available option; however, its significant adverse effect profile—including the risk of intestinal necrosis—has prompted a paradigm shift toward newer agents: patiromer and sodium zirconium cyclosilicate (SZC). This communication critically appraises pharmacology, evidence base, dosing strategies, monitoring requirements and practical considerations for using PBAs in the ICU. We highlight that SZC offers the most favorable profile for acute critical care, with rapid onset and renal-safe pharmacodynamics while patiromer remains suitable for sub-acute or chronic management. Appropriate patient selection, dose titration, drug–drug interaction screening and vigilant monitoring of electrolytes are essential to the safe use of these agents in the ICU.