SUN-856 - IV Regular Insulin Versus IV Insulin Aspart for Treatment of Acute Hyperkalemia in the Hospital Setting

Introduction and

Objective:

Insulin is a cornerstone therapy for acute hyperkalemia as it lowers serum potassium by promoting intracellular potassium (K) uptake via activation of the Na⁺/K⁺-ATPase. Although intravenous (IV) regular insulin is traditionally recommended for acute hyperkalemia treatment, substantial practice variation exists in real-world inpatient settings, where rapid-acting insulin analogs such as IV insulin aspart are used instead. Whether these pharmacokinetic differences translate into differences in potassium-lowering efficacy or hypoglycemia risk in hospitalized patients remains unclear. The aim of this study was to evaluate the potassium-lowering efficacy and hypoglycemia risk of IV regular insulin versus insulin aspart.

Methods:

This retrospective cohort study examined inpatients treated for moderate/severe hyperkalemia (potassium > 6 but < 10 mEq/L) from January 2017 to April 2023. Patients aged > 18 years who received IV insulin regular or aspart were included. The primary outcome was rate of K normalization (potassium < 5.4 mEq/L). Secondary outcomes included absolute and relative decrease in K, rate of any hypoglycemia (blood glucose < 70 mg/dL), stage 2 hypoglycemia ( < 54 mg/dL), or severe hypoglycemia ( < 40 mg/dL). Chi square, Mann-Whitney U, multivariate logistic regression, and multivariate linear regression tests were used to compare between groups (GraphPad Prism 10.3.1). Analyses were adjusted for baseline K or glucose, presence of CKD Stage 4-5, diabetes type, insulin dose, dextrose co-administration, time between insulin administration and lab recheck, and demographic variables.

Results:

A total of 3340 patients were evaluated, 1794 of whom received IV regular and 1546 of whom received IV aspart. Patient characteristics were mostly similar between groups (Baseline K: 6.7 vs 6.6 mEq/L, %CKD 75 vs 69%, A1c 7.2 vs 6.9%; %T2D 25.3 vs 22.7%). K normalized in 33.1 vs 37.2% patients (p=0.02). Median absolute ∆K was –1.1 vs –1.2 mEq/L (p=0.10), whereas median relative K was –16.4% vs –17.7% (p=0.03). Post-treatment hypoglycemia rates were slightly lower in IV Regular patients (8.3 vs 10.8%; p=0.04), but not for Stage 2 (3.9 vs 5.2%; p=0.12) or severe hypoglycemia (1.5 vs 2.2%; p=0.21). In multivariate analyses, regular insulin was no different than aspart in normalizing K (OR 0.90, 95%CI 0.73-1.10; p=0.31) or causing hypoglycemia (OR 1.43, 95%CI 0.96-2.13; p=0.08). Rates of Stages 2 or severe hypoglycemia also were no different between groups in regression analyses (p>0.05).

Conclusion:

There was no significant difference in the rates of potassium normalization or hypoglycemia observed when using IV regular vs aspart insulin for acute hyperkalemia management in the inpatient setting. Further studies are warranted to confirm these findings.

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