Calcium Polystyren Sulphonate

Pharmacologic Category

Antidote

Dosing: Adult

Hyperkalemia: Initiate treatment if potassium level >6 mmol/L (6 mEq/L); discontinue when potassium ≤5 mmol/L (5 mEq/L).

Oral: Usual dose: 15 g 3 to 4 times daily; dose should be based on clinical presentation and serum electrolyte levels

Rectal: 30 g once daily

Dosing: Geriatric

Refer to adult dosing.

Dosing: Renal Impairment: Adult

There are no specific dosage adjustments provided in the manufacturer’s labeling; however, dosage adjustments may be necessary based on changes in serum potassium and/or calcium levels.

Dosing: Hepatic Impairment: Adult

There are no dosage adjustments provided in the manufacturer’s labeling

Dosing: Pediatric

Hyperkalemia: Initiate treatment if potassium level >6 mmol/L (6 mEq/L); discontinue when potassium ≤5 mmol/L (5 mEq/L). In small children and infants, employ lower doses by using the practical exchange ratio of 1 mEq potassium per gram of resin as the basis for calculation.

Neonates: Rectal: 0.5 to 1 g/kg/dose

Children:

Oral (preferred route): Initial: 1 g/kg daily in divided doses; Maintenance: May reduce dose to 0.5 g/kg daily in divided doses

Rectal: Initial: 1 g/kg daily in divided doses; Maintenance: May reduce dose to 0.5 g/kg daily in divided doses

Dosing: Renal Impairment: Pediatric

There are no specific dosage adjustments provided in the manufacturer's labeling; however, dosage adjustments may be necessary based on changes in serum potassium and/or calcium levels.

Dosing: Hepatic Impairment: Pediatric

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

Use: Labeled Indications

Note: Not approved in the US

Hyperkalemia: Treatment of hyperkalemia

Administration: Oral

Administer orally (via nasogastric tube if unable to swallow) at least 3 hours before or 3 hours after other oral medications (patients with gastroparesis may require a 6 hour separation) as a prepared suspension or paste. Patient should be positioned carefully during ingestion to avoid aspiration. Note: More rapid lowering of potassium may be achieved with concomitant oral and rectal administration. Rectal route may be discontinued once orally administered resin has reached rectum. Oral administration in neonates is contraindicated.

Administration: Rectal

Enema route is less effective than oral administration. Administer rectally as a prepared suspension.

Enema should be retained as long as possible (product labeling suggests for at least 9 hours in adults or as long as possible) as greater amounts of potassium are excreted as retention time increases. Follow enema with irrigation to remove resin. Note: More rapid lowering of potassium may be achieved with concomitant oral and rectal administration. Rectal route may be discontinued once orally administered resin has reached rectum.

Administration: Pediatric

Oral: Infants, Children, and Adolescents: Administer orally (via nasogastric tube if unable to swallow) as a prepared suspension or paste with honey, jam, or liquids with low potassium content. Patient should be positioned carefully during ingestion to avoid aspiration. Note: More rapid lowering of potassium may be achieved with concomitant oral and rectal administration. Rectal route may be discontinued once orally administered resin has reached rectum. Oral administration in neonates is contraindicated.

Rectal: Enema route is less effective than oral administration. Administer rectally as suspension: Neonates, Infants, Children, and Adolescents: Enema should be retained as long as possible (product labeling suggests for at least 9 hours in adults or as long as possible) as greater amounts of potassium are excreted as retention time increases. Follow enema with irrigation to remove resin. Note: More rapid lowering of potassium may be achieved with concomitant oral and rectal administration. Rectal route may be discontinued once orally administered resin has reached rectum.

Dietary Considerations

May administer orally with honey, jam, or liquids with low potassium content. Do not mix in fruit juices (eg, orange juice) or other beverages with high potassium content. Some products may contain sodium.

Storage/Stability

Store between 15°C to 30°C (59°F to 86°F).

Preparation for Administration: Adult

Oral: Prepare a suspension or paste by mixing each 1 gram of resin with 3 to 4 mL of water or sweetened beverage (avoid fruit juices such as orange juice or other beverages with high potassium content).

Rectal: Mix 30 g of resin with 2% methylcellulose (100 mL) and water (100 mL).

Preparation for Administration: Pediatric

Oral: Prepare a suspension or paste by mixing in a small amount of water or sweetened beverage (avoid fruit juices, carbonated beverages, or other beverages with high potassium content); in adults, the manufacturer recommends mixing each 1 g of resin with 3 to 4 mL.

Rectal:

Neonates: Mix appropriate dose with 2% methylcellulose and water (eg, mix 3 g in 2% methylcellulose [10 mL] and water [10 mL] and administer weight-appropriate dose).

Children: Mix appropriate dose in a proportional amount of 10% dextrose in water

Adolescents: Mix 30 g of resin with 2% methylcellulose (100 mL) and water (100 mL)

Medication Safety Issues

Sound-alike/look-alike issues:

Contraindications

Hypersensitivity to polystyrene sulfonate resins or any component of the formulation; potassium <5 mmol/L (5 mEq/L); conditions associated with hypercalcemia (eg, metastatic carcinoma, multiple myeloma, hyperparathyroidism, or sarcoidosis); obstructive bowel disease; oral administration in neonates; use in neonates with reduced gut motility (postoperative, drug induced)

Warnings/Precautions

Concerns related to adverse effects:

• Electrolyte disturbances: Use may be associated with electrolyte disturbances including hypokalemia, hypercalcemia, and/or hypomagnesemia. Closely monitor electrolytes during therapy. Discontinue use if potassium ≤5 mmol/L (5 mEq/L).

• GI effects: Gastrointestinal stenosis, intestinal ischemia, ischemic colitis, rectal hemorrhage, gastrointestinal necrosis, and intestinal perforation with fatal outcomes have been reported, particularly in patients with underlying risk factors (eg, prematurity, history of intestinal disease or surgery, renal impairment, hypovolemia, severe burn, immunosuppressive therapy). Fecal impaction with rectal administration and concretion formation with oral administration have also occurred. Effects may be related to use of sorbitol enema with inadequate/absence of lavage after resin use. Avoid excess dosing or inadequate dilution with rectal administration to avoid resin impaction. Discontinue use in patients with clinically significant constipation. Intermittent therapy may be considered for patients developing nausea/vomiting, diarrhea, gastric irritation and anorexia, and the use of mild laxatives may be considered if constipation occurs.

Disease-related concerns:

• Renal impairment: Use with caution in renal impairment and/or dialysis patients. Sudden increases in calcium may be observed; monitor calcium weekly (or more frequently if clinically indicated). Dosage adjustments may be necessary.

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:

• Neonates/infants: Oral administration is contraindicated in neonates. Use caution with rectal administration to avoid resin impaction. Premature/low-birth-weight infants may be at risk for GI hemorrhage or colonic necrosis.

Pregnancy Considerations

Does not undergo gastrointestinal (GI) absorption. There are no adequate and well-controlled studies in pregnant women. In general, medications used as antidotes should take into consideration the health and prognosis of the mother; antidotes should be administered to pregnant women if there is a clear indication for use and should not be withheld because of fears of teratogenicity (Bailey 2003).

Breast-Feeding Considerations

Does not undergo GI absorption

Adverse Reactions

Frequency not defined:

Endocrine & metabolic: Hypokalemia

Gastrointestinal: Anorexia, constipation, diarrhea, gastric irritation, nausea, vomiting

Respiratory: Acute bronchitis, bronchopneumonia

<1%, postmarketing, and/or case reports: Bezoar formation (oral administration), fecal impaction (rectal administration), gastrointestinal necrosis, gastrointestinal obstruction (rare), gastrointestinal ulcer, hypercalcemia, hypomagnesemia, intestinal stenosis, ischemic colitis, mesenteric ischemia, rectal hemorrhage

Metabolism/Transport Effects

None known.

Drug Interactions Open Interactions

Aluminum Hydroxide: Calcium 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. Risk D: Consider therapy modification

Antacids: May enhance the adverse/toxic effect of Calcium Polystyrene Sulfonate. The combined use of these two agents may result in metabolic alkalosis and/or loss of efficacy of the cation 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 CPS effects. Avoid magnesium hydroxide. Risk D: Consider therapy modification

Cardiac Glycosides: Calcium Polystyrene Sulfonate may enhance the adverse/toxic effect of Cardiac Glycosides. Risk C: Monitor therapy

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

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

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

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

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

Monitoring Parameters

Close monitoring of serum electrolytes (potassium, sodium, calcium, magnesium); ECG

Reference Range

Serum potassium: Adults: 3.5 to 5.2 mEq/L

Product Availability

Not available in the US

Dosage Forms: Canada

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

Powder for suspension, oral/rectal:

Resonium Calcium: 300 g [contains calcium 1.6 to 2.4 mmol/g, sodium <1 mg/g; packaging contains 15 g measuring device]

Anatomic Therapeutic Chemical (ATC) Classification

• V03AE01

Mechanism of Action

Removes potassium by exchanging calcium ions for potassium ions in the intestine before the resin is excreted from the body

Pharmacodynamics/Kinetics

Onset of action: May be delayed 1 to 2 days due to GI transit time

Absorption: None

Excretion: Feces (100%)

Local Anesthetic/Vasoconstrictor Precautions

No information available to require special precautions

Effects on Dental Treatment

No significant effects or complications reported

Effects on Bleeding

No information available to require special precautions

Pharmacotherapy Pearls

In vitro exchange capacity is 1.3 to 2 mmol/g of potassium, while in vivo potassium binding capacity is less,

Index Terms

Calcium Polystyrene Sulphonate; Polystyrene Sulfonate Calcium

References

Bailey B, "Are There Teratogenic Risks Associated With Antidotes Used in the Acute Management of Poisoned Pregnant Women?" Birth Defects Res A Clin Mol Teratol, 2003, 67(2):133-40.[PubMed 12769509]

Resonium Calcium (calcium polystyrene sulfonate) [product monograph]. Laval, Quebec, Canada: Sanofi Aventis Canada Inc; September 2018.[PubMed 19751641]

Brand Names: International

Argamate (KR); Cal-Bind (LK); Calcium Resonium (AU, HK, IE, IN, KW, MT, PL, SA); Calcuim Resonium (CN); Kalimate (JP, MY, PH, TH, TW); Kalitake (ID); Kalitaker (KR); Kinelene (TH); Less-K (TH); Polyren (ID); Resical (BH, CZ, HU, PT); Resikali (FR); Resincalcio (AR, MY, TH); Resonium (VN); Sorbisterit (AT, BE, CH, CL, DE, DK, EE, ES, FI, GB, LT, LU, NL, SE, SI, SK)

Last Updated 2/16/20