eMedicine Specialties > Nephrology > Acid-Base, Fluid, and Electrolyte Disorders

Metabolic Alkalosis: Treatment & Medication

Author: Sameer Yaseen, MD, Staff Nephrologist, Department of Internal Medicine, Division of Nephrology, Mercy Hospital of Des Moines
Coauthor(s): Christie P Thomas, MBBS, FRCP, FASN, FAHA, Professor, Department of Internal Medicine, Division of Nephrology; Medical Director, Kidney and Kidney/Pancreas Transplant Program, University of Iowa Hospitals and Clinics
Contributor Information and Disclosures

Updated: Aug 18, 2009

Treatment

Medical Care

The management of metabolic alkalosis depends primarily on the underlying etiology and on the volume status of the patient. In the case of vomiting, administer antiemetics, if possible. If continuous gastric suction is necessary, gastric acid secretion can be reduced with H2-blockers or more efficiently with proton-pump inhibitors. In patients who are on thiazide or loop diuretics, the dose can be reduced or the drug can be stopped if appropriate. Alternatively, potassium-sparing diuretics or acetazolamide can be added.

  • Chloride-responsive alkalosis (general)
    • If chloride-responsive alkalosis occurs with volume depletion, treat the alkalosis with an intravenous infusion of isotonic sodium chloride solution. Because this type of alkalosis is usually associated with hypokalemia, also use potassium chloride to correct the hypokalemia.
    • If chloride-responsive alkalosis occurs in the setting of edematous states (eg, congestive heart failure [CHF]), use potassium chloride to correct the alkalosis instead of sodium chloride to avoid volume overload. If diuresis is needed, a carbonic anhydrase inhibitor (eg, acetazolamide) or a potassium-sparing diuretic (eg, spironolactone, amiloride, triamterene) can be used to correct the alkalosis.
  • Chloride-resistant metabolic alkalosis (specific) - Depends on underlying cause
    • Primary hyperaldosteronism: Metabolic alkalosis is corrected with the aldosterone antagonist spironolactone or with other potassium-sparing diuretics (eg, amiloride, triamterene). If the cause of primary hyperaldosteronism is an adrenal adenoma or carcinoma, surgical removal of the tumor should correct the alkalosis. In glucocorticoid-remediable hyperaldosteronism, metabolic alkalosis and hypertension are responsive to dexamethasone.
    • Cushing syndrome: Potassium-sparing diuretics should correct the alkalosis until surgical therapy. Definitive therapy includes transsphenoidal microresection of ACTH-producing pituitary adenomas and adrenalectomy for adrenal tumors.
    • Syndrome of AME: Metabolic alkalosis may be treated with potassium-sparing diuretics. On the other hand, dexamethasone may be used to suppress cortisol production by inhibiting ACTH. Unlike cortisol and some synthetic glucocorticoids, dexamethasone does not activate the mineralocorticoid receptor.
    • Licorice ingestion: Discontinuation of licorice ingestion corrects the alkalosis; however, because full recovery of the enzyme 11B-HSD may occur as long as 2 weeks following long-term licorice use, potassium-sparing diuretics can be used during this interval.
    • Bartter syndrome and Gitelman syndrome: Metabolic alkalosis can be corrected partially with potassium supplementation, potassium-sparing diuretics, nonsteroidal anti-inflammatory drugs, or ACE inhibitors.
    • Liddle syndrome: Metabolic alkalosis can be treated with amiloride or triamterene but not with spironolactone. Both amiloride and triamterene inhibit the apical sodium ion channel in the collecting duct. Spironolactone, which is an MR antagonist working upstream of the defective sodium ion channel, does not correct the alkalosis or the hypertension.
  • All metabolic alkalosis (specialized)
    • Hydrochloric acid: Intravenous HCl is indicated in severe metabolic alkalosis (pH >7.55) or when sodium or potassium chloride cannot be administered because of volume overload or advanced renal failure. HCl may also be indicated if rapid correction of severe metabolic alkalosis is warranted (eg, cardiac arrhythmias, hepatic encephalopathy, digoxin cardiotoxicity). Seek the advice of a nephrologist when severe alkalosis is present and HCl therapy or dialysis is contemplated.
    • Dialysis: Both peritoneal dialysis and hemodialysis can be used with certain modifications of the dialysate to correct metabolic alkalosis. The main indication of dialysis in metabolic alkalosis is in patients with advanced renal failure, who usually have volume overload and are resistant to acetazolamide. With hemodialysis, metabolic alkalosis may be corrected by using a low-bicarbonate dialysate (bicarbonate can be as low as 18 mmol/L). Otherwise, acetate-free biofiltration (buffer-free dialysate), in which bicarbonate is not present in the dialysate but is infused separately as needed, may be used. In peritoneal dialysis, dialysis can be performed using isotonic sodium chloride solution as the dialysate.

Consultations

Seek the advice of a nephrologist when severe alkalosis is present and HCl therapy or dialysis is contemplated.

Medication

Carbonic anhydrase inhibitors and HCl are used to treat metabolic alkalosis.7

Carbonic anhydrase inhibitors

Diuretics may be used to treat severe metabolic alkalosis in edematous states (eg, CHF, COPD, right heart failure).


Acetazolamide (Diamox)

Inhibits carbonic anhydrase, the enzyme that catalyzes the hydration of CO2 and dehydration of carbonic acid. Inhibition reduces reabsorption of NaHCO3 in proximal tubule, leading to natriuresis, bicarbonate, diuresis, and a decreased serum bicarbonate. As NaHCO3 delivery to the collecting duct increases, potassium secretion enhances, resulting in hypokalemia.

Adult

250-500 mg PO q6h
5 mg/kg IV qd

Pediatric

Not established

Can decrease lithium levels; alters excretion of certain drugs (eg, amphetamines, quinidine, phenobarbital, salicylates) by causing alkalinization of the urine; increases cyclosporine toxicity; may increase salicylate toxicity

Documented hypersensitivity; hepatic disease; severe renal disease; adrenocortical insufficiency; severe pulmonary obstruction; volume depletion; severe hypokalemia

Pregnancy

C - Safety for use during pregnancy has not been established.

Precautions

Concomitant administration with aspirin has been reported to cause anorexia, tachypnea, lethargy, coma, and death; caution in COPD or other lung disease associated with CO2 retention (may lead to more CO2 retention and hypoxemia); correct hypokalemia before beginning therapy

Acids

IV acidic solutions are used to treat severe metabolic alkalosis. Seek the advice of nephrologist in severe alkalosis when HCl therapy or dialysis is contemplated.


Hydrochloric acid

IV HCl may be indicated in severe metabolic alkalosis (pH >7.55) or when NaCl or KCl cannot be administered because of volume overload or advanced renal failure. Also may be indicated if rapid correction of severe metabolic alkalosis is warranted (eg, cardiac arrhythmia, hepatic encephalopathy, digoxin toxicity).
Preparations: 0.1-0.2 M, which contain 100 mmol H+/L and 200 mmol H+/L, respectively.

Adult

0.5 X lean body weight (kg) X desired decrement in plasma HCO3 - (mEq/L) IV infusion; not to exceed 0.2 mmol/kg/h; 15-20 mEq/h

Pediatric

Administer as in adults

Administration via a peripheral intravenous line

Pregnancy

C - Safety for use during pregnancy has not been established.

Precautions

Administer through central line in ICU; monitor ABGs and serum electrolytes

Potassium-sparing diuretics

May be used to correct potassium deficiency or fluid/electrolyte imbalance.


Triamterene (Dyrenium)

Interferes with potassium/sodium exchange (active transport) in distal tubule, cortical collecting tubule, and collecting duct by inhibiting sodium/potassium ATPase. Decreases calcium excretion and increases magnesium loss.

Adult

100 mg PO bid

Pediatric

Not established

Concurrent use with amiloride, spironolactone, or ACE inhibitors increases risk of hyperkalemia; amantadine plasma levels may increase and urinary excretion may decrease; cimetidine increases bioavailability and decreases clearance; avoid concurrent use with indomethacin because of increased risk of renal failure

Documented hypersensitivity; hyperkalemia; diabetes; renal impairment; concurrent use of potassium supplements, amiloride, or spironolactone unless documented evidence of unresponsiveness

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Caution in severe hepatic encephalopathy, diabetes, renal dysfunction, and history of renal stones; monitor BUN and serum potassium to check kidney function; can cause mild nitrogen retention (reversible upon withdrawal); photosensitization and megaloblastic anemia may occur


Spironolactone (Aldactone)

Aldosterone antagonist that competitively inhibits binding to aldosterone receptor. Competes for receptor sites in distal renal tubules and increases water excretion while retaining potassium and hydrogen ions needed to restore acid-base balance.

Adult

50-100 mg PO q6h

Pediatric

Not established

May decrease effect of anticoagulants; potassium and potassium-sparing diuretics may increase risk of hyperkalemia

Documented hypersensitivity; anuria; renal failure; hyperkalemia

Pregnancy

D - Unsafe in pregnancy

Precautions

Caution in renal and hepatic impairment


Amiloride (Midamor)

A pyrazine-carbonyl-guanidine unrelated chemically to other known antikaliuretic or diuretic agents. Potassium-conserving (antikaliuretic) drug that, compared with thiazide diuretics, possesses weak natriuretic, diuretic, and antihypertensive activity.

Adult

5-20 mg PO qd

Pediatric

Not established

NSAIDs decrease effects; ACE inhibitors, potassium preparations, and potassium-sparing diuretics increase risk of hyperkalemia; increased toxicity of lithium and amantadine

Documented hypersensitivity; hyperkalemia; potassium supplementation; impaired renal function; concurrent use of potassium-sparing diuretics; diabetic nephropathy

Pregnancy

B - Usually safe but benefits must outweigh the risks.

Precautions

Monitor electrolytes closely with evidence of renal function impairment, ie, BUN >30 mg/100 mL or serum creatinine levels >1.5 mg/100 mL; caution in severe hepatic encephalopathy, diabetes, and potassium retention associated with use of an antikaliuretic agent (accentuated in presence of renal impairment and may result in rapid development of hyperkalemia); monitor BUN and serum potassium; mild hyperkalemia is usually not associated with abnormal findings on ECG; can cause mild nitrogen retention, reversible upon withdrawal; photosensitization

Angiotensin-converting enzyme inhibitors

Block conversion of angiotensin I to angiotensin II and prevent secretion of aldosterone from the adrenal cortex.


Captopril (Capoten)

Prevents conversion of angiotensin I to angiotensin II, a potent vasoconstrictor, resulting in lower aldosterone secretion.

Adult

6.25-50 mg PO tid

Pediatric

Not established

NSAIDs may reduce hypotensive effects of captopril; ACE inhibitors may increase digoxin, lithium, and allopurinol levels; rifampin decreases captopril levels; probenecid may increase captopril levels; the hypotensive effects of ACE inhibitors may be enhanced when administered concurrently with diuretics

Documented hypersensitivity; renal impairment

Pregnancy

C - Safety for use during pregnancy has not been established.

Precautions

Caution in renal impairment, valvular stenosis, or severe CHF


Enalapril (Vasotec)

Competitive inhibitor of ACE. Reduces angiotensin II levels, decreasing aldosterone secretion.

Adult

2.5-20 mg PO qd

Pediatric

Not established

May increase digoxin, lithium, and allopurinol levels; rifampin decreases levels; probenecid may increase levels; diuretics may enhance hypotensive effects; NSAIDs may reduce hypotensive effects

Pregnancy

C - Safety for use during pregnancy has not been established.

Precautions

Caution in renal impairment, valvular stenosis, or severe CHF


Lisinopril (Prinivil, Zestril)

Prevents conversion of angiotensin I to angiotensin II, a potent vasoconstrictor, resulting in lower aldosterone secretion.

Adult

5-20 mg PO qd

Pediatric

Not established

May increase digoxin, lithium, and allopurinol levels; probenecid may increase levels; diuretics increase hypotensive effects; NSAIDs may reduce hypotensive effects

Pregnancy

C - Safety for use during pregnancy has not been established.

Precautions

Caution in renal impairment, valvular stenosis, or severe CHF

Potassium supplements

May be used to correct metabolic alkalosis.


Potassium chloride (K-Dur, Gen-K, Klor-Con)

Essential for transmission of nerve impulses, contraction of cardiac muscle, maintenance of intracellular tonicity, skeletal and smooth muscles, and maintenance of normal renal function.

Adult

20-120 mEq PO qd

Pediatric

Not established

Concurrent use with ACE inhibitors may result in elevated serum potassium concentrations; potassium-sparing diuretics and potassium-containing salt substitutes can produce severe hyperkalemia; in patients taking digoxin, hypokalemia may result in digoxin toxicity; caution if discontinuing potassium administration in patients maintained on digoxin

Documented hypersensitivity; hyperkalemia; renal failure; oliguria; azotemia; crush syndrome; anuria; adrenocortical insufficiency; potassium retention

Pregnancy

A - Safe in pregnancy

Precautions

Do not infuse rapidly; high plasma concentrations may cause death from cardiac depression, arrhythmias, or arrest; plasma levels do not necessarily reflect tissue levels; monitor replacement therapy whenever possible by continuous or serial ECG; when a concentration >40 mEq/L is infused, local pain and phlebitis may follow

Fluid replacements

Used in chloride-responsive alkalosis with volume depletion.


Sodium chloride (Adsorbonac, SalineX)

Volume expander solution used to correct metabolic imbalances.

Adult

Volume status dependent

Pediatric

Volume status dependent

May decrease levels of lithium when administered concurrently

Poor renal function; inadequate urine output; pulmonary edema (the added fluid promotes more edema); hypernatremia; hypertonic uterus

Pregnancy

A - Safe in pregnancy

Precautions

Interstitial edema; edema in the brain or lungs is potentially fatal; volume overload may occur in poor renal function; caution in CHF, hypertension, liver cirrhosis, and sodium toxicity

Corticosteroids

Used in glucocorticoid-remediable hyperaldosteronism, metabolic alkalosis, and hypertension.


Dexamethasone (Decadron, Dexone)

Used to suppress cortisol production by inhibiting ACTH. Does not activate mineralocorticoid receptor.

Adult

0.5-4 mg PO bid

Pediatric

Not established

Effects decrease with coadministration of barbiturates, phenytoin, and rifampin; dexamethasone decreases effect of salicylates and vaccines used for immunization

Documented hypersensitivity; active bacterial or fungal infection

Pregnancy

C - Safety for use during pregnancy has not been established.

Precautions

Increases risk of multiple complications, including severe infections; monitor adrenal insufficiency when tapering drug; abrupt discontinuation of glucocorticoids may cause adrenal crisis; hyperglycemia, edema, osteonecrosis, myopathy, peptic ulcer disease, hypokalemia, osteoporosis, euphoria, psychosis, myasthenia gravis, growth suppression, and infections are possible complications of glucocorticoid use

Nonsteroidal anti-inflammatory agents

May partially correct metabolic alkalosis in Bartter syndrome and Gitelman syndrome.


Ibuprofen (Motrin, Advil)

Inhibits inflammatory reactions and decreases prostaglandin synthesis.

Adult

400-600 mg PO q6h

Pediatric

5-10 mg/kg PO q6h

Coadministration with aspirin increases risk of inducing serious NSAID-related adverse effects; probenecid may increase concentrations and, possibly, toxicity of NSAIDs; may decrease effect of hydralazine, captopril, and beta-blockers; may decrease diuretic effects of furosemide and thiazides; may increase PT when taking anticoagulants (instruct patients to watch for signs of bleeding); may increase risk of methotrexate toxicity; phenytoin levels may be increased when administered concurrently

Documented hypersensitivity; peptic ulcer disease; recent GI bleeding or perforation; renal insufficiency; high risk of bleeding

Pregnancy

B - Usually safe but benefits must outweigh the risks.

Precautions

Pregnancy category D in third trimester; caution in CHF, hypertension, and decreased renal and hepatic function; caution in anticoagulation abnormalities or during anticoagulant therapy


Indomethacin (Indocin, Indochron E-R)

Rapidly absorbed. Metabolism occurs in liver by demethylation, deacetylation, and glucuronide conjugation. Inhibits prostaglandin synthesis.

Adult

25-50 mg PO q8h

Pediatric

1-3 mg/kg/d PO divided tid

Coadministration with aspirin increases risk of inducing serious NSAID-related adverse effects; probenecid may increase concentrations and, possibly, toxicity of NSAIDs; may decrease effect of hydralazine, captopril, and beta-blockers; may decrease diuretic effects of furosemide and thiazides; may increase PT when taking anticoagulants (instruct patients to watch for signs of bleeding); may increase risk of methotrexate toxicity; phenytoin levels may be increased when administered concurrently

Documented hypersensitivity; GI bleeding; renal insufficiency

Pregnancy

B - Usually safe but benefits must outweigh the risks.

Precautions

Pregnancy category D in third trimester; acute renal insufficiency, hyperkalemia, hyponatremia, interstitial nephritis, and renal papillary necrosis may occur; increases risk of acute renal failure in patients with preexisting renal disease or compromised renal perfusion; reversible leukopenia may occur, (discontinue if persistent leukopenia, granulocytopenia, or thrombocytopenia occurs)

More on Metabolic Alkalosis

Overview: Metabolic Alkalosis
Differential Diagnoses & Workup: Metabolic Alkalosis
Treatment & Medication: Metabolic Alkalosis
Follow-up: Metabolic Alkalosis
Multimedia: Metabolic Alkalosis
References
Further Reading

References

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Further Reading

Related eMedicine topics:
Alkalosis, Metabolic
Bartter Syndrome [Nephrology]
Bartter Syndrome [Pediatrics: General Medicine]
Hyperchloremic Acidosis
Hypertrophic Pyloric Stenosis
Hypertrophic Pyloric Stenosis, Surgical Treatment
Metabolic Acidosis [Emergency Medicine]
Metabolic Acidosis [Nephrology]
Respiratory Alkalosis

Clinical guidelines:
Evidence based clinical practice guideline hypertrophic pyloric stenosis. Cincinnati Children's Hospital Medical Center - Hospital/Medical Center.  2001 Aug 8 (revised 2007 Nov 4).  17 pages.  NGC:006224

Clinical trials:
Acetazolamide for Respiratory Failure in Combination With Metabolic Alkalosis
Treatment of Metabolic Alkalosis in Acute Exacerbations of Cystic Fibrosis

Keywords

metabolic alkalosis, alkalosis, metabolic acidosis, anion gap, respiratory alkalosis, respiratory metabolic alkalosis, bicarbonate, metabolic anion gap, contraction alkalosis, chloride-resistant alkalosis, chloride-responsive alkalosis

Contributor Information and Disclosures

Author

Sameer Yaseen, MD, Staff Nephrologist, Department of Internal Medicine, Division of Nephrology, Mercy Hospital of Des Moines
Sameer Yaseen, MD is a member of the following medical societies: American Society of Nephrology and Renal Physicians Association
Disclosure: Nothing to disclose.

Coauthor(s)

Christie P Thomas, MBBS, FRCP, FASN, FAHA, Professor, Department of Internal Medicine, Division of Nephrology; Medical Director, Kidney and Kidney/Pancreas Transplant Program, University of Iowa Hospitals and Clinics
Christie P Thomas, MBBS, FRCP, FASN, FAHA is a member of the following medical societies: American College of Physicians, American Federation for Medical Research, American Heart Association, American Society of Nephrology, American Society of Transplantation, American Thoracic Society, International Society of Nephrology, and Royal College of Physicians
Disclosure: Genzyme Grant/research funds Other

Medical Editor

Anil Kumar Mandal, MD, Clinical Professor, Department of Internal Medicine, Division of Nephrology, University of Florida School of Medicine
Anil Kumar Mandal, MD is a member of the following medical societies: American College of Clinical Pharmacology, American College of Physicians, American Society of Nephrology, and Central Society for Clinical Research
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

Eleanor Lederer, MD, Consulting Staff, Louisville VA Hospital; Professor of Medicine; Interim Chief of Nephrology; Director of Nephrology Training Program; Director, Metabolic Stone Clinic; Director of Outpatient Clinics, Kidney Disease Program, University of Louisville School of Medicine
Eleanor Lederer, MD is a member of the following medical societies: American Association for the Advancement of Science, American Federation for Medical Research, American Society for Biochemistry and Molecular Biology, American Society for Bone and Mineral Research, American Society of Nephrology, American Society of Transplantation, International Society of Nephrology, Kentucky Medical Association, National Kidney Foundation, and Phi Beta Kappa
Disclosure: Nothing to disclose.

CME Editor

Rebecca J Schmidt, DO, FACP, FASN, Professor of Medicine, Section Chief, Department of Medicine, Section of Nephrology, West Virginia University School of Medicine
Rebecca J Schmidt, DO, FACP, FASN is a member of the following medical societies: American College of Osteopathic Internists, American College of Physicians, American Medical Association, American Society of Nephrology, International Society of Nephrology, National Kidney Foundation, Renal Physicians Association, and West Virginia State Medical Association
Disclosure: Abbott Grant/research funds Speaking and teaching; Genzyme Honoraria Consulting; Amgen Honoraria Speaking and teaching; Ortho Biotech Honoraria Speaking and teaching

Chief Editor

Vecihi Batuman, MD, FACP, FASN, Professor of Medicine, Section of Nephrology-Hypertension, Tulane University School of Medicine; Chief, Medicine Service, Southeast Louisiana Veterans Health Care System
Vecihi Batuman, MD, FACP, FASN is a member of the following medical societies: American College of Physicians, American Society of Hypertension, American Society of Nephrology, and International Society of Nephrology
Disclosure: Nothing to disclose.

 
 
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