Pharmacological strategies to manage hyperkalaemia: out with the old, in with the new? Not so fast….

Since the 1950s, sodium polystyrene sulphonate (SPS) has been the dominant cation exchange agent prescribed for hyperkalaemia. Clinicians have had plenty of time to learn of SPS's advantages and limitations. The demands of drug regulatory agencies regarding the incorporation of medications into the market were not so stringent then as they are today, and the efficacy and safety of SPS have been questioned. In recent years, two novel cation exchangers, patiromer and sodium zirconium cyclosilicate, have received (or are in the process of receiving) regulatory approval in multiple jurisdictions globally, after scrutiny of carefully conducted trials regarding their short-term and mid-term efficacy. In this debate, we defend the view that all three agents are likely to have similar efficacy. Harms are much better understood for SPS than for newer agents, but currently there are no data to suggest that novel agents are safer than SPS. Drug choices need to consider costs, access and numbers-needed-to-treat to prevent clinically important events; for potassium exchangers, we need trials directly examining clinically important events.

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© The Author(s) 2023. Published by Oxford University Press on behalf of the ERA.

Déclaration de conflit d'intérêts

J.J.C. has conducted studies for which Karolinska Institutet has received support from AstraZeneca (manufacturer of SZC), Vifor Pharma (manufacturer of patiromer), Novo Nordisk, Astellas and Amgen. He also reports receiving lecture fees from Baxter, Fresenius, AstraZeneca, Astellas and Abbott and participated in advisory boards for AstraZeneca, Nestle and Bayer. M.M.S. is involved in studies of SZC supported by AstraZeneca and reports lecture fees from Otsuka, GlaxoSmithKline and Bayer. C.M.C. has received consultation, advisory board membership, honoraria or research funding from the Ontario Ministry of Health, Sanofi, Pfizer, Leo Pharma, Astellas, Janssen, Amgen, Boehringer Ingelheim and Baxter and through the LiV Academy of AstraZeneca. In 2018 she co-chaired a Kidney Disease: Improving global Outcomes (KDIGO) potassium controversies conference sponsored at arm’s length by Fresenius Medical Care, AstraZeneca, Vifor Fresenius Medical Care, Relypsa, Bayer HealthCare and Boehringer Ingelheim. She co-chairs the cloth mask knowledge exchange, a stakeholder group that includes cloth mask manufacturers and fabric distributors and is editor-in-chief of MaskEvidence.org. In 2019 she co-chaired the Canadian commentary on KDIGO metabolic bone disease guidelines, which was unfunded. She is a member of the Green Party of Ontario, American Society of Nephrology, Canadian Society of Nephrology (CSN), ASTM International and the American Association of Textile Chemists and Colorists. She is editor in chief of the Canadian Journal of Kidney Health and Disease, the official journal of the CSN. A.G.O. has no conflicts of interest to report.