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Sodium Polystyrene Sulfonate

Class: Potassium-removing Agents
VA Class: AD400
CAS Number: 9003-59-2
Brands: Kionex, SPS

Medically reviewed on Nov 12, 2018

Introduction

A sulfonated cation-exchange resin used for the removal of excess potassium.108 116 b

Uses for Sodium Polystyrene Sulfonate

Hyperkalemia

Treatment of hyperkalemia.108 116 b Used as an adjunct to other measures (e.g., restriction of electrolyte intake, control of acidosis, high-calorie diet).b

Prior to initiating therapy, determine cause of hyperkalemia and eliminate if possible.b

Because of its slow action (effective lowering of serum potassium may occur within hours to days),108 116 b sodium polystyrene sulfonate alone may be insufficient to rapidly correct severe hyperkalemia, including that associated with states of rapid tissue breakdown (e.g., burns, renal failure).108 b Not recommended for treatment of hyperkalemia evidenced by conduction defects (widening of the QRS complex) or arrhythmias.b

Most useful when hyperkalemia is not life-threatening or when other measures have reduced the dangers of hyperkalemia.b Do not use as an emergency treatment for life-threatening hyperkalemia.116 If severe hyperkalemia occurs, consider other definitive measures, including dialysis.108 b

Sodium Polystyrene Sulfonate Dosage and Administration

General

  • Dosage and duration of therapy must be individualized and depend on frequent assessment of total body potassium.108 116 b

Administration

Administer orally or rectally.108 116 b

Oral Administration

Administer orally ≥3 hours before or ≥3 hours after other orally administered drugs.115 116 In patients with gastroparesis, increase the separation time to 6 hours.115 116 (See Interactions.)

Administer orally as a suspension (either as the commercially available suspension108 b or prepared extemporaneously from the powdered resin).116 b

May be mixed with a diet appropriate for a patient in renal failure.108 Do not mix with foods or liquids that contain a large amount of potassium (e.g., bananas, orange juice).b

Suspension also may be introduced into the stomach via a tube.108 b

Prior to administration, shake suspension well.108

Follow full precautions to prevent aspiration (e.g., keep patient in upright position during administration).116

Reconstitution

Reconstitute each 1 g of the powdered resin in 3–4 mL of water or a syrup;116 usually 20–100 mL of fluid is used.b

Rectal Administration

Administer rectally as a retention enema by gravity feed (either as the commercially available suspension108 b or prepared extemporaneously from the powdered resin).116 b

Prior to administration, administer an initial cleansing enema, and then insert a soft, large (French 28) rubber tube about 20 cm into the rectum, with the tip well into the sigmoid colon, and tape in place.108 116 b

Prior to administration, warm suspension to body temperature108 116 b and shake well.108

During administration, stir the extemporaneously prepared suspension to keep it in suspension.b The tube may be flushed with 50–100 mL of fluid, clamped, and left in place.108 116 b If back-leakage occurs, the hips should be elevated on pillows or a knee-chest position assumed.108 b

Retain suspension in the colon for at least 30–60 minutesb or for several hours if possible,108 b then irrigate the colon with a non-sodium-containing solution at body temperature to remove the resin.108 116 b Returns should be drained constantly through a Y-tube connection.108 Approximately 2 L of irrigating solution may be needed to adequately flush out the resin;108 116 b proper removal of resin is particularly important if sorbitol is used (sorbitol use is not recommended).108

Alternatively, some clinicians recommend placing the resin in a sealed dialysis bag and inserting the bag into the rectum.b

Reconstitution

Suspend appropriate dose of powdered resin in 100–200 mL of an aqueous vehicle (e.g., 1% methylcellulose, 10% dextrose, water) at body temperature.116 b

A thicker suspension may be used; however, care should be taken that a paste, which would greatly reduce the exchange surface and be particularly ineffective if deposited in the rectal ampulla, is not formed.116 b

Dosage

Pediatric Patients

Hyperkalemia
Oral

Infants and small children: Reduced dosage recommended.108 Calculate dosage based on the fact that 1 g of the resin binds approximately 1 mEq of potassium.108 116 b

Oral administration contraindicated in neonates.108 (See Pediatric Use under Cautions.)

Rectal

Infants and small children: Reduced dosage recommended.108 Calculate dosage based on the fact that 1 g of the resin binds approximately 1 mEq of potassium.108 116 b

Some manufacturers state rectal administration is contraindicated in neonates and premature infants.108 (See Pediatric Use under Cautions.)

Adults

Hyperkalemia
Oral

15 g (approximately 4 level teaspoonfuls of the powder or 60 mL of the commercially available suspension) 1–4 times daily (average 15–60 g daily).108 116 b

Rectal

May administer 30–50 g (120–200 mL of the commercially available suspension) every 6 hours.108 116

Cautions for Sodium Polystyrene Sulfonate

Contraindications

  • Hypokalemia.108

  • Obstructive bowel disease.108 116

  • Neonates with decreased gut mobility.116

  • Oral administration contraindicated in neonates.108 Some manufacturers state that use (oral or rectal) is contraindicated in neonates and premature infants.108 (See Pediatric Use under Cautions.)

  • Known hypersensitivity to sodium polystyrene sulfonate resins.108 116

Warnings/Precautions

Serious Adverse GI Effects

Intestinal necrosis, which may be fatal, and other serious adverse GI events (bleeding, ischemic colitis, perforation) reported.108 109 110 116 Most cases involved concomitant sorbitol use; many of the patients had risk factors for adverse GI events (e.g., prematurity, history of intestinal disease or surgery, hypovolemia, renal insufficiency or failure).108 110 116

Concomitant administration of sorbitol not recommended.108 109 116 Most commercially available suspensions reformulated without sorbitol;108 112 however, preparations in 33% sorbitol vehicle remain commercially available.111 112

Use only in patients with normal bowel function.108 116 Avoid use in patients who have not had a bowel movement following surgery.108 116

Avoid use in patients at risk for developing constipation or impaction (e.g., those with history of fecal impaction, chronic constipation, inflammatory bowel disease, ischemic colitis, vascular intestinal atherosclerosis, previous bowel resection, or bowel obstruction).108 116

Discontinue use if constipation occurs.108 116

Electrolyte Disturbances

Possible severe hypokalemia (manifested by irritable confusion, delayed thought processes, muscle cramps, muscle weakness, and, occasionally, frank paralysis),108 116 b ECG abnormalities (e.g., lengthened QT intervals; widened, flat, or inverted T waves; prominent U waves), and cardiac abnormalities (e.g., premature atrial, nodal, or ventricular contractions; supraventricular and ventricular tachycardias) may occur.108 b

Intracellular potassium deficiency is not always reflected by serum potassium levels; individualize decision to discontinue sodium polystyrene sulfonate therapy, taking into account patient's clinical condition and ECG.108

Cation-exchange action is not totally selective for potassium; possible increased excretion of other cations (e.g., magnesium, calcium).108 116 b

Determine serum potassium concentrations frequently within each 24-hour period.108 116 Closely monitor ECGs and clinical condition of the patient during therapy.b

Monitor for other electrolyte (e.g., calcium, magnesium) abnormalities.108 116 b

Sodium Content

Each 1 g of the powdered resin contains approximately 4.1 mEq of sodium;116 b each 60 mL of the commercially available suspension contains 68.5 mEq of sodium.108

Clinically important sodium retention may occur.108 Use with caution in patients who cannot tolerate even a small increase in sodium loads (e.g., heart failure, hypertension, edema); restriction of sodium intake from other sources may be required.108 116 b

Pulmonary Effects

Acute bronchitis and bronchopneumonia caused by aspiration of sodium polystyrene sulfonate particles reported.116 Patients with an impaired gag reflex, altered level of consciousness, or predisposition to regurgitation may be at increased risk of aspiration.116

Take precautions to prevent aspiration (e.g., keep patient in upright position during oral administration).116

Binding to Other Drugs

May bind to other concomitantly administered oral drugs, reducing absorption and efficacy of these drugs; separate oral administration times by ≥3 hours (6 hours in those with gastroparesis).115 116 (See Interactions.)

Specific Populations

Pregnancy

Category C.108

Animal reproduction studies not performed.108 Not absorbed systemically following oral or rectal administration; use in pregnant women not expected to cause fetal harm.116

Lactation

Not absorbed systemically; breast-feeding not expected to result in risk to infants of sodium polystyrene sulfonate-treated women.116

Pediatric Use

Efficacy not established.108 116

Administer rectally with particular caution; excessive dosages or inadequate dilution may result in impaction of the resin.108 116 Ensure adequate volume of non-sodium-containing cleansing enemas after rectal administration.108

Premature or low-birthweight infants may have increased risk of adverse GI effects (e.g., intestinal necrosis) with sodium polystyrene sulfonate use.116 Some manufacturers state that use is contraindicated in premature infants.108

Contraindicated in neonates with reduced gut motility.116

Oral administration contraindicated in neonates.108 Some manufacturers state rectal administration also is contraindicated in neonates.108

Geriatric Use

Large doses in geriatric individuals may cause fecal impaction.108

Renal Impairment

Severe systemic alkalosis and a tonic-clonic seizure reported in one patient with chronic hypocalcemia secondary to renal failure who received magnesium hydroxide and sodium polystyrene sulfonate concomitantly.108 b (See Specific Drugs under Interactions.)

Common Adverse Effects

Gastric irritation,108 116 b anorexia,108 116 b constipation,108 116 b diarrhea,108 116 b fecal impaction,108 116 b GI concretions (bezoars),108 116 nausea,108 116 b vomiting,108 116 b hypokalemia,108 b hypocalcemia,108 b hypomagnesemia,108 clinically important sodium retention.108 b

Interactions for Sodium Polystyrene Sulfonate

Effects on GI Absorption of Drugs

May bind to other oral drugs, potentially reducing GI absorption of the drugs and resulting in loss of efficacy when administration times are close to those of oral sodium polystyrene sulfonate.115 116

Administer other oral agents ≥3 hours before or ≥3 hours after oral administration of sodium polystyrene sulfonate.115 116 In patients with gastroparesis or other conditions resulting in delayed gastric emptying, separate the administration times by 6 hours.115 116 Monitor clinical response and/or blood concentrations of the drugs whenever possible.105 116

Specific Drugs

Drug

Interaction

Comments

Amlodipine

Binds to amlodipine in vitro; possible decreased absorption and efficacy of amlodipine115 116

Separate oral administration times by ≥3 hours; increase separation time to 6 hours in patients with gastroparesis115 116

Monitor clinical response116

Amoxicillin

Binds to amoxicillin in vitro; possible decreased absorption and efficacy of amoxicillin115 116

Separate oral administration times by ≥3 hours; increase separation time to 6 hours in patients with gastroparesis115 116

Monitor clinical response116

Antacids, cation-donating (e.g., aluminum carbonate, aluminum hydroxide, magnesium hydroxide, calcium carbonate)

Possible reduced potassium exchange capability108 116 b

Concomitant oral administration of sodium polystyrene sulfonate may result in systemic alkalosis108 116 b

Possible intestinal obstruction due to concretions of aluminum hydroxide108 116 b

Concomitant use of oral sodium polystyrene sulfonate with magnesium hydroxide not recommended108

Rectal use of sodium polystyrene sulfonate may avoid systemic alkalosisb

Cardiac glycosides

Sodium polystyrene sulfonate-induced hypokalemia may increase toxic effects of cardiac glycosides on the heart (e.g., ventricular arrhythmias, AV nodal dissociation)108 (see Electrolyte Disturbances under Cautions)

Furosemide

Binds to furosemide in vitro; possible decreased absorption and efficacy of furosemide115 116

Separate oral administration times by ≥3 hours; increase separation time to 6 hours in patients with gastroparesis115 116

Monitor clinical response116

Laxatives, cation-donating

Possible reduced potassium exchange capability108 116 b

Concomitant oral administration of sodium polystyrene sulfonate may result in systemic alkalosis108 116 b

Concomitant use of oral sodium polystyrene sulfonate with magnesium hydroxide not recommended108

Rectal use of sodium polystyrene sulfonate may avoid systemic alkalosis)b

Lithium

Possible decreased absorption of lithium108 116

Separate oral administration times by ≥3 hours; increase separation time to 6 hours in patients with gastroparesis115 116

Monitor clinical response and/or blood concentrations108 116

Metoprolol

Binds to metoprolol in vitro; possible decreased absorption and efficacy of metoprolol115 116

Separate oral administration times by ≥3 hours; increase separation time to 6 hours in patients with gastroparesis115 116

Monitor clinical response116

Phenytoin

Binds to phenytoin in vitro; possible decreased absorption and efficacy of phenytoin115 116

Separate oral administration times by ≥3 hours; increase separation time to 6 hours in patients with gastroparesis115 116

Monitor clinical response and/or blood concentrations116

Sorbitol

Possible intestinal necrosis108 109 110 116

Concomitant administration not recommended108 109 116

Thyroxine

Possible decreased absorption of thyroxine 108 116

Separate oral administration times by ≥3 hours; increase separation time to 6 hours in patients with gastroparesis115 116

Monitor clinical response and/or blood concentrations108 116

Warfarin

Binds to warfarin in vitro; possible decreased absorption and efficacy of warfarin115 116

Separate oral administration times by ≥3 hours; increase separation time to 6 hours in patients with gastroparesis115 116

Monitor clinical response116

Sodium Polystyrene Sulfonate Pharmacokinetics

Absorption

Onset

Following administration, effective lowering of serum potassium may take hours to days.108 116

Elimination

Elimination Route

Modified resin is excreted in the feces.b

Stability

Storage

Oral or Rectal

Powder for Suspension

20–25°C; some preparations may be exposed to 15–30°C.116 117

Suspension (Sorbitol-free or in 33% Sorbitol Vehicle)

20–25°C; some preparations may be exposed to 15–30°C.108 111 If repackaged, refrigerate and use within 14 days of repackaging.108 111

Extemporaneous suspensions of the resin should be freshly prepared and should not be stored for >24 hours.116 b

Suspension should not be heated because changes in the exchange properties of the resin may occur.108 116 b

Actions

  • A cation-exchange resin used for the removal of excess potassium.108 116 b

  • Releases sodium in exchange for other cations (e.g., potassium, calcium, magnesium, iron, organic cations, lipids, steroids, proteins).b

  • Sodium is released from the resin in exchange for potassium primarily in the large intestine, where there is a relatively high concentration of potassium present.116 b Each 1 g of the resin has an in vitro exchange capacity of about 3.1 mEq of potassium; an in vivo exchange capacity >1 mEq of potassium per g of resin is not likely.108 116 b

Advice to Patients

  • Importance of advising patients to administer other oral drugs ≥3 hours before or ≥3 hours after oral administration of sodium polystyrene sulfonate.115 116

  • Importance of informing clinicians of existing or contemplated concomitant therapy, including prescription and OTC drugs, as well as any concomitant illnesses.108 116

  • Importance of women informing clinicians if they are or plan to become pregnant or plan to breast-feed.108 116

  • Importance of informing patients of other important precautionary information.108 116 (See Cautions.)

Preparations

Excipients in commercially available drug preparations may have clinically important effects in some individuals; consult specific product labeling for details.

Please refer to the ASHP Drug Shortages Resource Center for information on shortages of one or more of these preparations.

* available from one or more manufacturer, distributor, and/or repackager by generic (nonproprietary) name

Sodium Polystyrene Sulfonate

Routes

Dosage Forms

Strengths

Brand Names

Manufacturer

Oral or Rectal

Powder, for suspension

Kionex

Perrigo

Sodium Polystyrene Sulfonate Powder

Suspension

1.25 g/5 mL*

Kionex

Perrigo

Sodium Polystyrene Sulfonate Suspension

SPS

CMP

AHFS DI Essentials™. © Copyright 2018, Selected Revisions November 12, 2018. American Society of Health-System Pharmacists, Inc., 4500 East-West Highway, Suite 900, Bethesda, Maryland 20814.

References

100. Lillemoe KD, Romolo JL, Hamilton SR et al. Intestinal necrosis due to sodium polystyrene (Kayexalate) in sorbitol enemas: clinical and experimental support for the hypothesis. Surgery. 1987; 101:267-72. http://www.ncbi.nlm.nih.gov/pubmed/3824154?dopt=AbstractPlus

101. Wootton FT, Rhodes DF, Lee WM et al. Colonic necrosis with Kayexalate-sorbitol enemas after renal transplantation. Ann Intern Med. 1989; 111:947-9. http://www.ncbi.nlm.nih.gov/pubmed/2817643?dopt=AbstractPlus

102. Arvanitakis C, Malek G, Uehling D et al. Colonic complications after renal transplantation. Gastroenterology. 1973; 64:533-8. http://www.ncbi.nlm.nih.gov/pubmed/4144776?dopt=AbstractPlus

103. Burnett RJ. Sodium polystyrene-sorbitol enemas. Ann Intern Med. 1990; 112:311-2. http://www.ncbi.nlm.nih.gov/pubmed/2297214?dopt=AbstractPlus

104. Shepard KV. Cleansing enemas after sodium polystyrene sulfonate enemas. Ann Intern Med. 1990; 112:711. http://www.ncbi.nlm.nih.gov/pubmed/2334084?dopt=AbstractPlus

105. Food and Drug Administration. FDA drug safety communication: FDA requires drug interaction studies with potassium-lowering drug Kayexalate (sodium polystyrene sulfonate). Rockville, MD; 2015 Oct 22. From FDA website. Accessed 2016 Mar 3. http://www.fda.gov/Drugs/DrugSafety/ucm468035.htm

108. West-Ward Pharmaceuticals. Sodium polystyrene sulfonate suspension prescribing information. Eatontown, NJ; 2016 May.

109. McGowan CE, Saha S, Chu G et al. Intestinal necrosis due to sodium polystyrene sulfonate (Kayexalate) in sorbitol. South Med J. 2009; 102:493-7. http://www.ncbi.nlm.nih.gov/pubmed/19373153?dopt=AbstractPlus http://www.pubmedcentral.nih.gov/picrender.fcgi?tool=pmcentrez&artid=3638814&blobtype=pdf

110. Harel Z, Harel S, Shah PS et al. Gastrointestinal adverse events with sodium polystyrene sulfonate (Kayexalate) use: a systematic review. Am J Med. 2013; 126:264.e9-24.

111. CMP Pharma. Sodium polystyrene sulfonate suspension prescribing information. Farmville, NC; 2017 Jan.

112. Sterns RH, Rojas M, Bernstein P et al. Ion-exchange resins for the treatment of hyperkalemia: are they safe and effective?. J Am Soc Nephrol. 2010; 21:733-5. http://www.ncbi.nlm.nih.gov/pubmed/20167700?dopt=AbstractPlus

115. Food and Drug Administration. FDA drug safety communication: FDA recommends separating dosing of potassium-lowering drug sodium polystyrene sulfonate (Kayexalate) from all other oral drugs. Silver Spring, MD; 2017 Sep 6. From FDA website. Accessed 2018 Mar 12. https://www.fda.gov/Drugs/DrugSafety/ucm572484.htm

116. Perrigo. Kionex (sodium polystyrene sulfonate) powder for suspension prescribing information. Minneapolis, MN; 2017 Aug.

117. CMP Pharma. Sodium polystyrene sulfonate powder for suspension prescribing information. Farmville, NC; 2018 Mar.

b. AHFS Drug Information. McEvoy, GK, ed. Sodium Polystyrene Sulfonate. Bethesda, MD: American Society of Health-System Pharmacists.

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