388 Journal of Hospital Medicine ® Vol 14 | No 6 | June 2019 An Offcial Publication of the Society of Hospital Medicine LETTERS TO THE EDITOR In Response to “In Reference to: ‘Preventing Hypoglycemia Following Treatment of Hyperkalemia in Hospitalized Patients’” Charlotte K Boughton, MBBS, PhD 1,2 ; Danielle Dixon, MBBS 1,2 ; Emma Goble, MRPharmS 1,3 ; Alice Burridge, PhD 1,3 ; Alison Cox, RN 1,2 ; Georgia Noble-Bell, RN, MSc 1,2 ; Charlotte Bell, MRPharmS 1,3 ; Ben Fidler 1,4 ; James Chudley 1,4 ; Caroline Anderson, MRPharmS, FFCI 1,3 ; Gillian Cavell, MRPharmS, MSc 1,3 ; Omar G Mustafa, MBChB, FRCP 1,2 * 1 King’s Insulin Safety Group, King’s College Hospital NHS Foundation Trust, London, United Kingdom; 2 Department of Diabetes, King’s College Hospi- tal NHS Foundation Trust, London, United Kingdom; 3 Department of Pharmacy and Medications Safety, King’s College Hospital NHS Foundation Trust, London, United Kingdom; 4 Clinical Systems, King’s College Hospital NHS Foundation Trust, London, United Kingdom. W e appreciate the comments and interest of Al-Sharef and colleagues who highlight the use of glucose-only infusion in the management of hyperkalemia. 1 The incidence of hypoglycemia following hyperkalemia treatment with insulin/dextrose is high and measures to reduce this should be pursued. 2 However, evi- dence of the ef fcacy of glucose-only infusions on lowering po- tassium in heterogeneous inpatient populations is lacking. The small study by Chothia et al demonstrated potassium lowering ef fcacy in ten clinically stable patients without diabetes receiv- ing chronic hemodialysis. 3 In contrast, multiple observational studies consistently show a clinically signifcant effect of insulin/ dextrose on potassium lowering across different populations. 4 Importantly, inpatient hyperglycemia is associated with in- creased morbidity and mortality and occurs in those with preexist- ing diabetes and also those without, due to stress hyperglycemia from acute illness, medication or nutrition support. 5 Determin- ing intact insulin sensitivity during acute illness is not straight- forward and deciding on the appropriateness of glucose-only hyperkalemia treatment compared with insulin/dextrose would be challenging. With the rising prevalence of diabetes in the in- patient setting (>30% in our study), the number of eligible indi- viduals for glucose-only treatment would be small and does not justify the use of two separate hyperkalemia treatment protocols. Given the potential life-threatening consequences of hyper- kalemia, rapid potassium lowering is a priority. For glucose-on- ly infusions to be applied, there needs to be more convincing evidence across more representative inpatient populations to ensure effcacy. References 1. Al Sharef A, Quinton R, Roberts G. In Reference to: “Preventing Hypoglyce- mia Following Treatment of Hyperkalemia in Hospitalized Patients “. J Hosp Med. 2019;14(6):387. doi: 10.12788/jhm.3209. 2. Boughton CK, Dixon D, Goble E, Burridge A, Cox A, Noble-Bell G, et al. Pre- venting hypoglycemia following treatment of hyperkalemia in hospitalized patients. J Hosp Med. 2019;14(5):284-287. doi: 10.12788/jhm.3145. 3. Chothia MY, Halperin ML, Rensburg MA, Hassan MS, Davids MR. Bolus admin- istration of intravenous glucose in the treatment of hyperkalemia: a randomized controlled trial. Nephron Physiol. 2014;126(1):1-8. doi: 10.1159/000358836. 4. Harel Z, Kamel KS. Optimal dose and method of administration of intrave- nous insulin in the management of emergency hyperkalemia: a systematic review. PLoS One. 2016;11(5):e0154963. doi: 10.1371/journal.pone.0154963. e 5. Umpierrez GE, Isaacs SD, Bazargan N, You X, Thaler LM, Kitabchi AE. Hyperglycemia: an independent marker of in-hospital mortality in patients with undiagnosed diabetes. J Clin Endocrinol Metab. 2002;87(3):978-982. doi: 10.1210/jcem.87.3.8341. *Corresponding Author: Omar G Mustafa MBChB, FRCP; E-mail: omarmustafa@nhs.net; Telephone: (020) 3299-1588; Twitter: @OGMustafa Received: April 2, 2019; Accepted: April 2, 2019 © 2019 Society of Hospital Medicine DOI 10.12788/jhm.3218