High-Dose Potassium – Case Scenario

I get a little nervous when I see high-dose potassium. Here’s a case scenario where a patient is on a higher dose. WL is a 77 year old male in an assisted living facility. He has a history of CHF, anxiety, pain, GERD, BPH, and constipation. His current medication list includes;

Hydrochlorothiazide 12.5 mg QD
Lisinopril 5 mg QD
Potassium 40 meq TID
Tolterodine 2 mg at bedtime
Tamsulosin 0.4 mg QD
Senna 2 tablets QD
Norco 7.5/325 mg at bedtime + PRN
Omeprazole 20 mg BID
Buspirone 5 mg BID
Lorazepam 1 mg BID PRN

Click on the medication links above to learn more about these medications from the Real Life Pharmacology Podcast.

Here are my top 3 concerns with this medication regimen.

I would want to know what the most recent potassium level is given the relatively low dose of hydrochlorothiazide and the high dose of potassium. 120 meq of potassium is a significant dose and I have seen issues with hyperkalemia if labs are not monitored closely. I’ve seen errors with high dose potassium that have led to bad outcomes. I’ve found in practice that patients on high-dose potassium are often taking high dose loop diuretics. I would question if furosemide had been used in the past for fluid and is no longer necessary. The potassium should also be reassessed when reducing or discontinuing furosemide.

My next concern is the dose of lorazepam in combination with an opioid. This combination can increase the risk of respiratory depression. This interaction frequently comes up on board exams. In addition to the combination, the lorazepam dose is fairly high as well. There is plenty of room to increase buspirone to help with anxiety and reduce the need for and/or dosing of lorazepam.

With the history of heart failure, guideline-directed medical therapy is not being followed. There may be a reason for this but looking at adding and ARNI and/or beta-blocker would be considered as tolerated. Vital signs would be important to know prior to considering these changes.

What else concerns you about this high-dose potassium case?

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