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©2013 UpToDate ® Print Email Approach to patients at risk for hyperkalemia caused by inhibitors of the renin-angiotensin-aldosterone system Estimate glomerular filtration rate to assess specific risk of hyperkalemia Discontinue nonsteroidal antiinflammatory drugs and other drugs that interfere with renal potassium excretion Inquire about use of herbal preparations Prescribe a low-potassium diet Inquire about use of potassium-containing salt substitutes Prescribe thiazide or loop diuretics to increase potassium excretion Prescribe sodium bicarbonate to correct metabolic acidosis if present When initiating ACE inhibitor, angiotensin receptor blocker, or aldosterone receptor blocker therapy, use low doses Measure plasma potassium concentration one week after initiating therapy or after increasing dose of these agents If plasma potassium increases to ≤5.5 mmol/liter, decrease dose of drug and, if combination therapy is being given, discontinue one agent In plasma potassium increases to >5.5 mmol/liter despite above measures, discontinue these agents Adapted from: Palmer BF. Managing hyperkalemia caused by inhibitors of the renin- angiotensin-aldosterone system. N Engl J Med 2004; 351:585.