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Sodium Polystyrene Sulfonate

Pronunciation

(SOW dee um pol ee STYE reen SUL fon ate)

Dosage Forms

Excipient information presented when available (limited, particularly for generics); consult specific product labeling. [DSC] = Discontinued product

Powder, Oral:

Kalexate: (454 g [DSC]) [sorbitol free; contains sodium 100 mg (4.1 mEq)/g]

Kayexalate: (453.6 g) [contains sodium 100 mg (4.1 mEq)/g]

Kionex: (454 g) [contains sodium 100 mg (4.1 mEq)/g]

Generic: (15 g, 453.6 g, 454 g)

Suspension, Oral:

Kionex: 15 g/60 mL (60 mL, 473 mL) [contains alcohol, usp, methylparaben, propylene glycol, propylparaben, saccharin sodium, sodium 1500 mg (65 mEq)/60 mL, sorbitol; raspberry flavor]

SPS: 15 g/60 mL (60 mL, 120 mL, 473 mL) [contains alcohol, usp, methylparaben, propylene glycol, propylparaben, saccharin sodium, sodium 1500 mg (65 mEq)/60 mL, sorbitol; cherry flavor]

Generic: 15 g/60 mL (60 mL, 480 mL, 500 mL)

Suspension, Rectal:

Generic: 30 g/120 mL (120 mL); 50 g/200 mL (200 mL)

Brand Names: U.S.

  • Kalexate [DSC]
  • Kayexalate
  • Kionex
  • SPS

Pharmacologic Category

  • Antidote

Pharmacology

Removes potassium by exchanging sodium ions for potassium ions in the intestine (especially the large intestine) before the resin is passed from the body; the practical exchange capacity is 1 mEq potassium per 1 g of resin in vivo, and in vitro capacity is 3.1 mEq of potassium per 1 g of resin, therefore, a wide range of exchange capacity exists such that close monitoring of serum electrolytes is necessary.

Absorption

None

Excretion

Completely feces (primarily as potassium polystyrene sulfonate)

Onset of Action

Hours to days

Use: Labeled Indications

Hyperkalemia: Treatment of hyperkalemia.

Limitations of use: Due to delayed onset of action, sodium polystyrene sulfonate should not be used an emergency treatment for life threatening hyperkalemia.

Contraindications

Hypersensitivity to sodium polystyrene sulfonate, polystyrene sulfonate resins or any component of the formulation; hypokalemia (excluding Kayexalate); obstructive bowel disease; neonates with reduced gut motility; oral administration in neonates.

Additional contraindications: Suspension: Rectal administration in neonates (particularly in premature infants).

Dosing: Adult

Hyperkalemia:

Oral: 15 g 1 to 4 times daily.

Rectal: 30 to 50 g every 6 hours.

Dosing: Geriatric

Refer to adult dosing.

Dosing: Pediatric

Hyperkalemia:

Oral: Children: 1 g/kg/dose every 6 hours.

Rectal: Children: 1 g/kg/dose every 2 to 6 hours (in small children and infants, employ lower doses by using the practical exchange ratio of 1 mEq K+/g of resin as the basis for calculation).

Dosing: Renal Impairment

There are no dosage adjustments provided in the manufacturer's labeling. Use with caution; risks of gastrointestinal adverse effects are greater in patients with renal insufficiency or failure.

Dosing: Hepatic Impairment

There are no dosage adjustments provided in the manufacturer's labeling.

Reconstitution

Powder for suspension:

Oral or NG: For each 1 g of the powdered resin, add ~3 to 4 mL of water or syrup (amount of fluid usually ranges from 20 to 100 mL). Do not heat the solution to enhance dissolution of the powder as heating impairs the exchange resin properties.

Enema: Suspend dose in 100 mL of an aqueous vehicle (eg, water, sorbitol 25%, methylcellulose 1%, dextrose 10%).

Administration

Oral or NG: Administer orally or via NG tube with patient in an upright position at least 3 hours before or 3 hours after other medications (patients with gastroparesis may require a 6 hour separation). Do not mix in orange juice or in any fruit juice known to contain potassium. Shake the suspension well prior to administration. Chilling the oral mixture will increase palatability. Sodium polystyrene sulfonate suspension may also be added to the patient's food (with the exception of potassium-containing food such as bananas and orange juice).

Rectal: Administer cleansing enema first. Administer sodium polystyrene sulfonate as a warm emulsion (body temperature). During administration, the solution should be agitated gently. Retain the enema in the colon for at least 30 to 60 minutes and for several hours, if possible. Once retention time is complete, irrigate the colon with a nonsodium-containing solution to remove resin.

Dietary Considerations

Do not mix in orange juice or in any fruit juice known to contain potassium. Some products may contain sodium.

Storage

Store at 25°C (77°F); excursions permitted to 15°C to 30°C (59°F to 86°F). Store repackaged product in refrigerator and use within 14 days. Freshly prepared suspensions should be used within 24 hours. Do not heat resin suspension.

Drug Interactions

Aluminum Hydroxide: Sodium Polystyrene Sulfonate may enhance the adverse/toxic effect of Aluminum Hydroxide. More specifically, concomitant use of these agents may increase the risk for intestinal obstruction. Management: Monitor for signs/symptoms of intestinal obstruction with concomitant use of calcium polystyrene sulfonate and aluminum hydroxide. Adequate fluid intake, laxative use, alternative antacid agents, and/or limiting duration of therapy may help reduce risks. Consider therapy modification

Antacids: May enhance the adverse/toxic effect of Sodium Polystyrene Sulfonate. The combined use of these two agents may result in metabolic alkalosis and/or loss of efficacy of the exchange resin. Management: To minimize this interaction, consider: a)separating doses by 2 or more hours; b)rectal administration of the exchange resin; or c)alternatives to antacids. Monitor for metabolic alkalosis and attenuation of SPS effects. Avoid magnesium hydroxide. Exceptions: Sodium Bicarbonate. Consider therapy modification

Digoxin: Sodium Polystyrene Sulfonate may enhance the adverse/toxic effect of Digoxin. Monitor therapy

Laxatives (Magnesium Containing): May enhance the adverse/toxic effect of Sodium Polystyrene Sulfonate. More specifically, concomitant use of sodium polystyrene sulfonate with magnesium-containing laxatives may result in metabolic alkalosis or with sorbitol may result in intestinal necrosis. Management: Avoid concomitant use of sodium polystyrene sulfonate (rectal or oral) and magnesium-containing laxatives. Avoid combination

Lithium: Sodium Polystyrene Sulfonate may decrease the serum concentration of Lithium. Management: Consider separating administration of lithium from administration of oral sodium polystyrene sulfonate by at least 6 hours. Consider therapy modification

Meloxicam: May enhance the adverse/toxic effect of Sodium Polystyrene Sulfonate. More specifically, concomitant use of meloxicam oral suspension (which contains sorbitol) may increase the risk for intestinal necrosis. Avoid combination

Sorbitol: May enhance the adverse/toxic effect of Sodium Polystyrene Sulfonate. More specifically, concomitant use of these agents may increase the risk for intestinal necrosis. Avoid combination

Thyroid Products: Sodium Polystyrene Sulfonate may decrease the serum concentration of Thyroid Products. Management: To minimize risk of interaction, separate dosing of oral sodium polystyrene sulfonate and thyroid products (e.g., levothyroxine) or administer sodium polystyrene sulfonate rectally. Monitor for signs/symptoms of hypothyroidism with concomitant use (oral). Consider therapy modification

Adverse Reactions

Frequency not defined.

Endocrine & metabolic: Hypernatremia, hypocalcemia, hypokalemia, hypomagnesemia, sodium retention

Gastrointestinal: Anorexia, constipation, diarrhea, fecal impaction, nausea, vomiting

<1% (Limited to important or life-threatening): Bezoar formation, gastrointestinal hemorrhage, gastrointestinal ulcer, intestinal necrosis, intestinal perforation, ischemic colitis

Warnings/Precautions

Concerns related to adverse effects:

• Aspiration: Acute bronchitis and bronchopneumonia caused by inhalation of sodium polystyrene sulfonate particles have been reported; patients with impaired gag reflex, altered level of consciousness or patients prone to regurgitation may be at increased risk. Administer with the patient in an upright position.

• Electrolyte disturbances: Severe hypokalemia may occur; frequent monitoring of serum potassium is recommended within each 24-hour period; ECG monitoring may be appropriate in select patients. Cation-exchange resins may also affect other cation concentrations, possibly resulting in decreased serum magnesium and calcium.

• Fecal impaction: Large oral doses may cause fecal impaction (especially in elderly); rectal administration has been associated with fecal impaction in children.

• Intestinal necrosis: Intestinal necrosis (including fatalities) and other serious gastrointestinal events (eg, bleeding, ischemic colitis, perforation) have been reported, especially when administered with sorbitol; concomitant administration of sorbitol is not recommended. Increased risk may be associated with a history of intestinal disease or surgery, hypovolemia, prematurity, and renal insufficiency or failure. Use only in patients who have normal bowel function. Avoid use in any postoperative patient at risk for constipation or impaction until normal bowel function resumes; discontinue use if constipation occurs.

Disease-related concerns:

• Cardiovascular disease: Use with caution in patients with severe heart failure and/or hypertension; sodium load may exacerbate condition.

• Edema: Use with caution in patients with edema; sodium load may exacerbate condition.

• Renal impairment: Use with caution in patients with renal impairment.

Concurrent drug therapy issues:

• Drug-drug interactions: Potentially significant interactions may exist, requiring dose or frequency adjustment, additional monitoring, and/or selection of alternative therapy. Consult drug interactions database for more detailed information.

Special populations:

• Elderly: Higher doses in elderly patients may result in fecal impaction.

• Pediatric: Oral administration in neonates and use in neonates with reduced gut motility (postoperatively or drug-induced) is contraindicated. Oral or rectal administration of suspension in neonates (particularly with prematurity) is also contraindicated. Use with caution in premature or low-birth-weight infants. Use with caution in children when administering rectally; excessive dosage or inadequate dilution may result in fecal impaction.

Dosage form specific issues:

• Propylene glycol: Some dosage forms may contain propylene glycol; large amounts are potentially toxic and have been associated hyperosmolality, lactic acidosis, seizures, and respiratory depression; use caution (AAP 1997; Zar 2007).

Other warnings/precautions:

• Appropriate use: Effective lowering of serum potassium from sodium polystyrene sulfonate may take hours to days after administration; consider alternative measures (eg, dialysis) or concomitant therapy (eg, IV sodium bicarbonate) in situations where rapid correction of severe hyperkalemia is required.

• Enema vs oral administration: Enema will reduce the serum potassium faster than oral administration, but the oral route will result in a greater reduction over several hours.

Monitoring Parameters

Serum electrolytes (potassium, sodium, calcium, magnesium); ECG in select patients; signs/symptoms of fluid overload in patients sensitive to sodium intake (eg, heart failure, hypertension, edema).

Pregnancy Risk Factor

C

Pregnancy Considerations

Animal reproduction studies have not been conducted. Sodium polystyrene sulfonate is not absorbed systemically following oral or rectal administration. Use during pregnancy is not expected to result in significant exposure to the fetus.

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 lack of appetite, vomiting, or nausea. Have patient report immediately to prescriber signs of electrolyte problems (mood changes, confusion, muscle pain or weakness, abnormal heartbeat, seizures, lack of appetite, or severe nausea or vomiting), shortness of breath, excessive weight gain, severe headache, signs of bowel problems (black, tarry, or bloody stools; fever; mucus in stools; vomiting; vomiting blood; severe abdominal pain; constipation; or diarrhea), severe diarrhea, severe headache, shortness of breath, excessive weight gain, or swelling of arms or legs (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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