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Potassium Phosphate

Pronunciation

(poe TASS ee um FOS fate)

Index Terms

  • Phosphate, Potassium

Dosage Forms

Excipient information presented when available (limited, particularly for generics); consult specific product labeling.

Injection, solution: Potassium 4.4 mEq and phosphorus 3 mmol per mL (5 mL, 15 mL, 50 mL) [equivalent to potassium 170 mg and elemental phosphorus 93 mg per mL]

Brand Names: U.S.

  • Neutra-Phos®-K [OTC] [DSC]

Pharmacologic Category

  • Electrolyte Supplement, Parenteral

Pharmacology

Phosphorus in the form of organic and inorganic phosphate has a variety of important biochemical functions in the body and is involved in many significant metabolic and enzymatic reactions in almost all organs and tissues. It exerts a modifying influence on the steady state of calcium levels, a buffering effect on acid-base equilibrium and a primary role in the renal excretion of hydrogen ion.

Potassium is the major cation of intracellular fluid and is essential for the conduction of nerve impulses in heart, brain, and skeletal muscle; contraction of cardiac, skeletal and smooth muscles; maintenance of normal renal function, acid-base balance, carbohydrate metabolism, and gastric secretion.

Excretion

Urine (>80% to 90% of dose reabsorbed by the kidney)

Use: Labeled Indications

Treatment and prevention of hypophosphatemia; Note: The concomitant amount of potassium must be calculated into the total electrolyte content. For each 1 mmol of phosphate, ~1.5 mEq of potassium will be administered. Therefore, if ordering 30 mmol of potassium phosphate, the patient will receive ~45 mEq of potassium.

Contraindications

Hyperphosphatemia, hyperkalemia, hypocalcemia

Dosing: Adult

Note: If phosphate repletion is required and a phosphate product is not available at your institution, consider the use of sodium glycerophosphate pentahydrate (Glycophos) as a suitable substitute. Concentration and dosing are different from FDA-approved products; use caution when switching between products. Refer to Sodium Glycerophosphate Pentahydrate monograph.

Caution: The concomitant amount of potassium must be calculated into the total electrolyte content. For each 1 mmol of phosphate, ~1.5 mEq of potassium will be administered. Therefore, if ordering 30 mmol of potassium phosphate, the patient will receive ~45 mEq of potassium. With orders for IV phosphate, there is considerable confusion associated with the use of millimoles (mmol) versus milliequivalents (mEq) to express the phosphate requirement. The most reliable method of ordering IV phosphate is by millimoles, then specifying the potassium or sodium salt. Doses listed as mmol of phosphate.

Acute treatment of hypophosphatemia: Repletion of severe hypophosphatemia should be done IV because large doses of oral phosphate may cause diarrhea and intestinal absorption may be unreliable. Reserve intermittent IV infusion for severe depletion situations; may require continuous cardiac monitoring depending on potassium administration rate. Guidelines differ based on degree of illness, need/use of parenteral nutrition, and severity of hypophosphatemia. If potassium >4.0 mEq/L consider phosphate replacement strategy without potassium (eg, sodium phosphates). Patients with severe renal impairment were excluded from phosphate supplement trials. Note: 1 mmol phosphate = 31 mg phosphorus; 1 mg phosphorus = 0.032 mmol phosphate.

General replacement guidelines (Lentz, 1978):

Low dose, if serum phosphate losses are recent and uncomplicated: Initial: 0.08 mmol/kg over 6 hours

Intermediate dose, if serum phosphorus level <1 mg/dL (<0.32 mmol/L): Initial: 0.16 mmol/kg per dose over 6 hours

Note: The initial dose may be increased by 25% to 50% if the patient is symptomatic secondary to hypophosphatemia and lowered by 25% to 50% if the patient is hypercalcemic. Do not exceed the maximum dose of 0.24 mmol/kg/dose (or 16.9 mmol for a 70-kg patient).

Critically-ill adult patients receiving concurrent enteral/parenteral nutrition (Brown, 2006; Clark, 1995): Note: Round doses to the nearest 7.5 mmol for ease of preparation. If administering with phosphate-containing parenteral nutrition, do not exceed 15 mmol/L within parenteral nutrition.

Low dose, serum phosphorus level 2.3-3 mg/dL (0.74-0.96 mmol/L): 0.16-0.32 mmol/kg over 4-6 hours

Intermediate dose, serum phosphorus level 1.6-2.2 mg/dL (0.51-0.71 mmol/L): 0.32-0.64 mmol/kg over 4-6 hours

High dose, serum phosphorus <1.5 mg/dL (<0.5 mmol/L): 0.64-1 mmol/kg over 8-12 hours

Obesity: May use adjusted body weight for patients weighing >130% of ideal body weight (and BMI<40 kg/m2) by using [IBW + 0.25 (actual body weight - IBW)].

Parenteral nutrition: IV: 10-15 mmol/1000 kcal (Hicks, 2001) or 20-40 mmol/24 hours (Mirtallo, 2004 [ASPEN guidelines])

Dosing: Geriatric

Refer to adult dosing.

Dosing: Pediatric

Note: If phosphate repletion is required and a phosphate product is not available at your institution, consider the use of sodium glycerophosphate pentahydrate (Glycophos) as a suitable substitute. Concentration and dosing are different from FDA-approved products; use caution when switching between products. Refer to Sodium Glycerophosphate Pentahydrate monograph.

Caution: The concomitant amount of potassium must be calculated into the total electrolyte content. For each 1 mmol of phosphate, ~1.5 mEq of potassium will be administered. Therefore, if ordering 30 mmol of potassium phosphate, the patient will receive ~45 mEq of potassium. With orders for IV phosphate, there is considerable confusion associated with the use of millimoles (mmol) versus milliequivalents (mEq) to express the phosphate requirement. The most reliable method of ordering IV phosphate is by millimoles, then specifying the potassium or sodium salt. Doses listed as mmol of phosphate.

Intermittent IV infusion should be reserved for severe depletion situations; may require continuous cardiac monitoring depending on potassium administration rate. It is difficult to determine total body phosphorus deficit. There are no prospective studies of parenteral phosphate replacement in children. The following weight-based guidelines for adult dosing may be cautiously employed in pediatric patients. Guidelines differ based on degree of illness, use of TPN, and severity of hypophosphatemia. Note: 1 mmol phosphate = 31 mg phosphorus; 1 mg phosphorus = 0.032 mmol phosphate.

General replacement guidelines (Lentz, 1978):

Low dose, if serum phosphate losses are recent and uncomplicated: Initial: 0.08 mmol/kg over 6 hours

Intermediate dose, if serum phosphorus level <1 mg/dL (<0.32 mmol/L): Initial: 0.16 mmol/kg per dose over 6 hours

Note: The initial dose may be increased by 25% to 50% if the patient is symptomatic secondary to hypophosphatemia and lowered by 25% to 50% if the patient is hypercalcemic. Do not exceed the maximum dose of 0.24 mmol/kg/dose (or 16.9 mmol for a 70-kg patient).

Critically-ill adult patients receiving concurrent enteral/parenteral nutrition (Brown, 2006; Clark, 1995): Note: Round doses to the nearest 7.5 mmol for ease of preparation. If administering with phosphate-containing parenteral nutrition, do not exceed 15 mmol/L within parenteral nutrition.

Low dose, serum phosphorus level 2.3-3 mg/dL (0.74-0.96 mmol/L): 0.16-0.32 mmol/kg over 4-6 hours

Intermediate dose, serum phosphorus level 1.6-2.2 mg/dL (0.51-0.71 mmol/L): 0.32-0.64 mmol/kg over 4-6 hours

High dose, serum phosphorus <1.5 mg/dL (<0.5 mmol/L): 0.64-1 mmol/kg over 8-12 hours

Obesity: May use adjusted body weight for patients weighing >130% of ideal body weight (and BMI<40 kg/m2) by using [IBW + 0.25 (actual body weight - IBW)].

Parenteral nutrition:

Infants and Children: 0.5-2 mmol/kg/24 hours (Mirtallo, 2004 [ASPEN guidelines])

Children >50 kg and Adolescents: 10-40 mmol/24 hours (Mirtallo, 2004 [ASPEN guidelines])

Dosing: Obesity

Refer to indication-specific dosing for obesity-related information (may not be available for all indications).

Reconstitution

In general, the dose, concentration of infusion, and rate of administration may be dependent on patient condition and specific institution policy. Intermittent infusion doses of potassium phosphate are typically prepared in 100-250 mL of NS or D5W (usual phosphate concentration range: 0.15-0.6 mmol/mL) (Charron, 2003; Rosen, 1995). Suggested maximum concentrations:

Central line administration: 26.8 mmoL potassium phosphate/100 mL (40 mEq potassium/100 mL)

Peripheral line administration: 6.7 mmoL potassium phosphate/100 mL (10 mEq potassium/100 mL)

Observe the vial for the presence of translucent visible particles. Do not use vial if particles are present. Dilute in a compatible IV fluid. Note: Due to the potential presence of particulates, American Regent, Inc recommends the use of a 5 micron filter when preparing IV potassium phosphate-containing solutions (Important Drug Administration Information, American Regent, 2011); a similar recommendation has not been noted by other manufacturers.

Administration

Injection must be diluted in appropriate IV solution and volume prior to administration. In general, the dose, concentration of infusion, and rate of administration may be dependent on patient condition and specific institution policy. Must consider administration precautions for phosphate and potassium when prescribing. Note: Due to the potential presence of translucent visible particles, American Regent, Inc recommends the use of a 0.22 micron in-line filter for IV administration (1.2 micron filter if admixture contains lipids) (Important Drug Administration Information, American Regent, 2011); a similar recommendation has not been noted by other manufacturers.

For adult patients with severe symptomatic hypophosphatemia (ie, <1.5 mg/dL), may administer at rates up to 15 mmol phosphate/hour (this rate will deliver potassium at 22.5 mEq/hour) (Charron 2003; Rosen 1995). Potassium infusion rates >10 mEq/hour should be administered via central line (minimizes burning and phlebitis). ECG monitoring is recommended for potassium infusions >10 mEq/hour in adults or >0.5 mEq/kg/hour in children. In patients with renal dysfunction and/or less severe hypophosphatemia, slower administration rates (eg, over 4 to 6 hours) or oral repletion is recommended.

Vesicant/irritant (may depend on concentration); ensure proper needle or catheter placement prior to and during IV infusion. Avoid extravasation.

Extravasation management: If extravasation occurs, stop infusion immediately and disconnect (leave needle/cannula in place); gently aspirate extravasated solution (do NOT flush the line); initiate hyaluronidase antidote; remove needle/cannula; apply dry cold compresses (Hurst 2004); elevate extremity.

Hyaluronidase: Intradermal or SubQ: Inject a total of 1 mL (15 units/mL) as five separate 0.2 mL injections (using a 25-gauge needle) into area of extravasation at the leading edge in a clockwise manner (MacCara 1983; Zenk 1981).

Compatibility

Stable in D10LR, D51/4NS, D51/2NS, D5NS, D5W, D10W, 1/2NS, NS; incompatible with D5LR, D10NS, LR.

Y-site administration: Incompatible with amiodarone, caspofungin, ciprofloxacin, doripenem, pantoprazole.

Compatibility in syringe: Incompatible with aminophylline, pantoprazole.

Storage

Store intact vials at 20°C to 25°C (68°F to 77°F); excursions permitted between 15°C and 30°C (59°F and 86°F).

Drug Interactions

ACE Inhibitors: Potassium Salts may enhance the hyperkalemic effect of ACE Inhibitors. Monitor therapy

Aliskiren: Potassium Salts may enhance the hyperkalemic effect of Aliskiren. Monitor therapy

Angiotensin II Receptor Blockers: Potassium Salts may enhance the hyperkalemic effect of Angiotensin II Receptor Blockers. Monitor therapy

Antacids: May decrease the absorption of Phosphate Supplements. Management: This applies only to oral phosphate administration. Separating administer of oral phosphate supplements from antacid administration by as long as possible may minimize the interaction. Consider therapy modification

Calcium Salts: May decrease the absorption of Phosphate Supplements. Management: This applies only to oral phosphate and calcium administration. Administering oral phosphate supplements as far apart from the administration of an oral calcium salt as possible may be able to minimize the significance of the interaction. Consider therapy modification

Eplerenone: May enhance the hyperkalemic effect of Potassium Salts. Management: This combination is contraindicated in patients receiving eplerenone for treatment of hypertension. Consider therapy modification

Heparin: May enhance the hyperkalemic effect of Potassium Salts. Monitor therapy

Heparin (Low Molecular Weight): May enhance the hyperkalemic effect of Potassium Salts. Monitor therapy

Iron Salts: May decrease the absorption of Phosphate Supplements. Management: This applies only to oral phosphate and iron administration. Administer oral phosphate supplements at least 1 hour before, or 2 hours after, oral iron salt administration. Exceptions: Ferric Carboxymaltose; Ferric Gluconate; Ferric Hydroxide Polymaltose Complex; Ferric Pyrophosphate Citrate; Ferumoxytol; Iron Dextran Complex; Iron Sucrose. Consider therapy modification

Magnesium Salts: May decrease the serum concentration of Phosphate Supplements. Management: This applies only to oral phosphate and magnesium administration. Administer oral phosphate supplements at least 1 hour before, or 2 hours after, oral magnesium salt administration. Consider therapy modification

Multivitamins/Minerals (with ADEK, Folate, Iron): May decrease the serum concentration of Phosphate Supplements. Management: This applies only to oral phosphate and multivitamin administration. Administer oral phosphate supplements at least 1 hour before, or 2 hours after, administration of an iron-containing multivitamin. Consider therapy modification

Nicorandil: May enhance the hyperkalemic effect of Potassium Salts. Monitor therapy

Potassium-Sparing Diuretics: Potassium Salts may enhance the hyperkalemic effect of Potassium-Sparing Diuretics. Consider therapy modification

Sucralfate: May decrease the absorption of Phosphate Supplements. Management: This applies only to oral phosphate administration. Administering oral phosphate supplements at least 1 hour before or 2 hours after administration of sucralfate may reduce the significance of the interaction. Consider therapy modification

Adverse Reactions

Frequency not defined.

Cardiovascular: Bradycardia, cardiac arrhythmia, chest pain, ECG changes, edema, heart block, hypotension, localized phlebitis

Central nervous system: Confusion, lethargy, paralysis, paresthesia

Endocrine & metabolic: Hyperkalemia

Gastrointestinal: Diarrhea, nausea, stomach pain, vomiting

Genitourinary: Decreased urine output

Neuromuscular & skeletal: Tetany (with large doses of phosphate), weakness

Renal: Acute renal failure

Respiratory: Dyspnea

Warnings/Precautions

Concerns related to adverse effects:

• Extravasation: Vesicant/irritant (may depend on concentration); ensure proper catheter or needle position prior to and during infusion. Avoid extravasation.

• Hyperkalemia: Close monitoring of serum potassium concentrations is needed to avoid hyperkalemia; severe hyperkalemia may lead to muscle weakness/paralysis and cardiac conduction abnormalities (eg, heart block, ventricular arrhythmias, asystole).

Disease-related concerns:

• Acid/base disorders: Use with caution in patients with acid/base alterations; changes in serum potassium concentrations can occur during acid/base correction, monitor closely.

• Cardiovascular disease: Use with caution in patients with cardiovascular disease (eg, heart failure, cardiac arrhythmias); patients may be more susceptible to life-threatening cardiac effects associated with hyper/hypokalemia.

• Renal impairment: Use with caution in patients with renal impairment; renal impairment requires close monitoring of serum potassium and phosphorus concentrations to avoid hyperkalemia and/or hyperphosphatemia.

Concurrent drug therapy issues:

• Digoxin: Use with caution in digitalized patients; may be more susceptible to potentially life-threatening cardiac effects with rapid changes in serum potassium concentrations.

• Potassium-altering therapies: Use with caution in patients receiving concomitant medications or therapies that increase potassium (eg, ACEI, potassium-sparing diuretics, potassium containing salt substitutes).

Dosage form specific issues:

• Aluminum: The parenteral product may contain aluminum; toxic aluminum concentrations may be seen with high doses, prolonged use, or renal dysfunction. Premature neonates are at higher risk due to immature renal function and aluminum intake from other parenteral sources. Parenteral aluminum exposure of >4 to 5 mcg/kg/day is associated with CNS and bone toxicity; tissue loading may occur at lower doses (Federal Register, 2002). See manufacturer’s labeling.

Other warnings/precautions:

• Calcium/phosphate compatibility: Admixture of phosphate and calcium in IV fluids can result in calcium phosphate precipitation.

• Parenteral administration: Use extreme caution when administering potassium phosphate parenterally; evaluate patient's renal function, cardiac and fluid status, and any factors contributing to altered potassium concentrations (eg, acidosis, alkalosis) prior to therapy. Closely monitor potassium and phosphate concentrations and response to therapy. Parenteral potassium may cause pain and phlebitis, requiring a decrease in infusion rate or potassium concentration.

Monitoring Parameters

Serum potassium, calcium, phosphorus, magnesium (to facilitate potassium repletion); cardiac monitor (if intermittent infusion or potassium infusion rates >0.5 mEq/kg/hour in children or >10 mEq/hour in adults); to assess adequate replacement, repeat serum potassium and phosphorus levels 2-4 hours after dose

Pregnancy Risk Factor

C

Pregnancy Considerations

Reproduction studies have not been conducted. Phosphorus requirements are the same in pregnant and nonpregnant women (IOM, 1997). Although this product is not used for potassium supplementation, adverse events have not been observed following use of potassium supplements in healthy women with normal pregnancies. Use caution in pregnant women with other medical conditions (eg, pre-eclampsia; may be more likely to develop hyperkalemia) (IOM, 2004).

Patient Education

• Discuss specific use of drug and side effects with patient as it relates to treatment. (HCAHPS: During this hospital stay, were you given any medicine that you had not taken before? Before giving you any new medicine, how often did hospital staff tell you what the medicine was for? How often did hospital staff describe possible side effects in a way you could understand?)

• Patient may experience abdominal pain, nausea, vomiting, or diarrhea. Have patient report immediately to prescriber signs of high potassium (abnormal heartbeat, confusion, dizziness, passing out, weakness, shortness of breath, numbness or tingling feeling), signs of low calcium (muscle cramps or spasms, numbness and tingling, or seizures), or angina (HCAHPS).

• Educate patient about signs of a significant reaction (eg, wheezing; chest tightness; fever; itching; bad cough; blue skin color; seizures; or swelling of face, lips, tongue, or throat). Note: This is not a comprehensive list of all side effects. Patient should consult prescriber for additional questions.

Intended Use and Disclaimer: Should not be printed and given to patients. This information is intended to serve as a concise initial reference for health care professionals to use when discussing medications with a patient. You must ultimately rely on your own discretion, experience, and judgment in diagnosing, treating, and advising patients.

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