Sodium polystyrene sulfonate

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# Overview
Sodium polystyrene sulfonate is a polymer derived from polystyrene that is FDA approved for the treatment of hyperkalemia.   Common adverse reactions include anorexia, nausea, vomiting, and constipation.

# Adult Indications and Dosage

## FDA-Labeled Indications and Dosage (Adult)

## Indications
- Sodium polystyrene sulfonate Suspension is indicated for the treatment of hyperkalemia.

## Dosage
- The average daily adult dose is 15 g (60 mL) to 60 g (240 mL) of suspension. This is best provided by administering 15 g (60 mL) of Sodium polystyrene sulfonate Suspension one to four times daily. Each 60 mL of Sodium polystyrene sulfonate Suspension contains 1500 mg (65 mEq) of sodium. Since the in vivo efficiency of sodium-potassium exchange resins is approximately 33%, about one-third of the resin's actual sodium content is being delivered to the body.
- In smaller children and infants, lower doses should be employed by using as a guide a rate of 1 mEq of potassium per gram of resin as the basis for calculation.
- Sodium polystyrene sulfonate Suspension may be introduced into the stomach through a plastic tube and, if desired, given with a diet appropriate for a patient in renal failure.
- Sodium polystyrene sulfonate Suspension may also be given, although with less effective results, as an enema consisting (for adults) of 30 g (120 mL) to 50 g (200 mL) every six hours. The enema should be retained as long as possible and followed by a cleansing enema.
- After an initial cleansing enema, a soft, large size (French 28) rubber tube is inserted into the rectum for a distance of about 20 cm, with the tip well into the sigmoid colon, and taped into place. The suspension is introduced at body temperature by gravity. The suspension is flushed with 50 or 100 mL of fluid, following which the tube is clamped and left in place. If back leakage occurs, the hips are elevated on pillows or a knee-chest position is taken temporarily. The suspension is kept in the sigmoid colon for several hours, if possible. Then the colon is irrigated with a sodium-free cleansing enema at body temperature in order to remove the resin. Two quarts of flushing solution may be necessary. The returns are drained constantly through a Y tube connection. Particular attention should be paid to the cleansing enema, because sorbitol is present in the vehicle.
- The intensity and duration of therapy depend upon the severity and resistance of hyperkalemia.
- Sodium polystyrene sulfonate Suspension should not be heated for to do so may alter the exchange properties of the resin.

## Off-Label Use and Dosage (Adult)

### Guideline-Supported Use
- There is limited information regarding Off-Label Guideline-Supported Use of Sodium polystyrene sulfonate in adult patients.

### NonGuideline-Supported Use
- There is limited information regarding Off-Label NonGuideline-Supported Use of Sodium polystyrene sulfonate in adult patients.

# Pediatric Indications and Dosage

## FDA-Labeled Indications and Dosage (Pediatric)
- The effectiveness of Sodium polystyrene sulfonate Suspension in pediatric patients has not been established.

## Off-Label Use and Dosage (Pediatric)

### Guideline-Supported Use
- There is limited information regarding Off-Label Guideline-Supported Use of Sodium polystyrene sulfonate in pediatric patients.

### NonGuideline-Supported Use
- There is limited information regarding Off-Label NonGuideline-Supported Use of Sodium polystyrene sulfonate in pediatric patients.

# Contraindications
- Sodium polystyrene sulfonate Suspension is contraindicated in the following conditions: patients with hypokalemia, patients with a history of hypersensitivity to polystyrene sulfonate resins, obstructive bowel disease, oral or rectal administration in neonates (particularily in premature infants), and in any post-operative patient until normal bowel function resumes.

# Warnings
- Alternative Therapy in Severe Hyperkalemia:
- Since the effective lowering of serum potassium with sodium polystyrene sulfonate may take hours to days, treatment with this drug alone may be insufficient to rapidly correct severe hyperkalemia associated with states of rapid tissue breakdown (e.g., burns and renal failure) or hyperkalemia so marked as to constitute a medical emergency. Therefore, other definitive measures, including dialysis, should always be considered and may be imperative.
- Hypokalemia:
- Serious potassium deficiency can occur from sodium polystyrene sulfonate therapy. The effect must be carefully controlled by frequent serum potassium determinations within each 24 hour period. Since intracellular potassium deficiency is not always reflected by serum potassium levels, the level at which treatment with sodium polystyrene sulfonate should be discontinued must be determined individually for each patient. Important aids in making this determination are the patient's clinical condition and electrocardiogram. Early clinical signs of severe hypokalemia include a pattern of irritable confusion and delayed thought processes.
- Electrocardiographically, severe hypokalemia is often associated with a lengthened Q-T interval, widening, flattening, or inversion of the T wave, and prominent U waves. Also, cardiac arrhythmias may occur, such as premature atrial, nodal, and ventricular contractions, and supraventricular and ventricular tachycardias. The toxic effects of digitalis are likely to be exaggerated. Marked hypokalemia can also be manifested by severe muscle weakness, at times extending into frank paralysis.
- Electrolyte Disturbances:
- Like all cation-exchange resins, sodium polystyrene sulfonate is not totally selective (for potassium) in its actions, and small amounts of other cations such as magnesium and calcium can also be lost during treatment. Accordingly, patients receiving sodium polystyrene sulfonate should be monitored for all applicable electrolyte disturbances.
- Systemic Alkalosis:
- Systemic alkalosis has been reported after cation-exchange resins were administered orally in combination with nonabsorbable cation-donating antacids and laxatives such as magnesium hydroxide and aluminum carbonate. Magnesium hydroxide should not be administered with sodium polystyrene sulfonate. One case of grand mal seizure has been reported in a patient with chronic hypocalcemia of renal failure who was given sodium polystyrene sulfonate with magnesium hydroxide as a laxative.

## Precautions
- Caution is advised when sodium polystyrene sulfonate is administered to patients who cannot tolerate even a small increase in sodium loads (i.e., severe congestive heart failure, severe hypertension, or marked edema). In such instances, compensatory restriction of sodium intake from other sources may be indicated.
- Caution is advised when Sodium polystyrene sulfonate Suspension is administered to patients with end stage diabetic renal disease.
- Sodium polystyrene sulfonate Suspension should not be administered to patients following surgery until normal bowel function resumes.
- Precautions should be taken to ensure the use of adequate volumes of sodium-free cleansing enemas after rectal administration.
- In the event of clinically significant constipation, treatment with Sodium polystyrene sulfonate Suspension should be discontinued until normal bowel motion is resumed. Magnesium-containing laxatives should not be used.

# Adverse Reactions

## Clinical Trials Experience
- Sodium polystyrene sulfonate Suspension may cause some degree of gastric irritation. Anorexia, nausea, vomiting, and constipation may occur especially if high doses are given. Also, hypokalemia, hypocalcemia, and significant sodium retention may occur. Occasionally diarrhea develops. Large doses in elderly individuals may cause fecal impaction. Rare instances of colonic necrosis have been reported. Intestinal obstruction due to concretions of aluminum hydroxide, when used in combination with sodium polystyrene sulfonate, has been reported.
- The following events have been reported from worldwide post marketing experience with sodium polystyrene sulfonate powder:
- fecal impaction following rectal administration, particularly in children;
- gastrointestinal concretions (bezoars) following oral administration;
- gastrointestinal tract ulceration or necrosis which could lead to intestinal perforation; and,
- rare cases of acute bronchitis and/or bronchopneumonia associated with inhalation of particles of polystyrene sulfonate.

## Postmarketing Experience
- There is limited information regarding postmarketing experience

# Drug Interactions
- Antacids: The simultaneous oral administration of sodium polystyrene sulfonate with non-absorbable cation-donating antacids and laxatives may reduce the resin's potassium exchange capability.
- Non-absorbable cation-donating antacids and laxatives: Systemic alkalosis has been reported after cation exchange resins were administered orally in combination with nonabsorbable cation-donating antacids and laxatives such as magnesium hydroxide and aluminum carbonate. Magnesium hydroxide should not be administered with sodium polystyrene sulfonate. One case of grand mal seizure has been reported in a patient with chronic hypocalcemia of renal failure who was given sodium polystyrene sulfonate with magnesium hydroxide as a laxative.
- Intestinal obstruction due to concretions of aluminum hydroxide when used in combination with sodium polystyrene sulfonate has been reported.
- Digitalis: The toxic effects of digitalis on the heart, especially various ventricular arrhythmias and A-V nodal dissociation, are likely to be exaggerated by hypokalemia, even in the face of serum digoxin concentrations in the "normal range".
- Sorbitol: Concomitant use of additional sorbitol with Sodium polystyrene sulfonate Suspension is not recommended.
- Lithium: Sodium polystyrene sulfonate Suspension may decrease absorption of lithium.
- Thyroxine: Sodium polystyrene sulfonate Suspension may decrease absorption of thyroxine.

# Use in Specific Populations

### Pregnancy
Pregnancy Category (FDA): C
- Animal reproduction studies have not been conducted with sodium polystyrene sulfonate. It is also not known whether sodium polystyrene sulfonate can cause fetal harm when administered to a pregnant woman or can affect reproduction capacity. Sodium polystyrene sulfonate should be given to a pregnant woman only if clearly needed.
Pregnancy Category (AUS): 
There is no Australian Drug Evaluation Committee (ADEC) guidance on usage of Sodium polystyrene sulfonate in women who are pregnant.

### Labor and Delivery
There is no FDA guidance on use of Sodium polystyrene sulfonate during labor and delivery.

### Nursing Mothers
- It is not known whether this drug is excreted in human milk. Because many drugs are excreted in human milk, caution should be exercised when sodium polystyrene sulfonate is administered to a nursing woman.

### Pediatric Use
- The effectiveness of Sodium polystyrene sulfonate Suspension in pediatric patients has not been established. The use of Sodium polystyrene sulfonate Suspension is contraindicated in neonates and especially in premature infants. In children, particular care should be observed with rectal administration, as excessive dosage or inadequate dilution could result in impaction of the resin. Precaution should be taken to ensure the use of adequate volumes of sodium-free cleansing enemas after rectal administration.

### Geriatic Use
There is no FDA guidance on the use of Sodium polystyrene sulfonate in geriatric settings.

### Gender
There is no FDA guidance on the use of Sodium polystyrene sulfonate with respect to specific gender populations.

### Race
There is no FDA guidance on the use of Sodium polystyrene sulfonate with respect to specific racial populations.

### Renal Impairment
There is no FDA guidance on the use of Sodium polystyrene sulfonate in patients with renal impairment.

### Hepatic Impairment
There is no FDA guidance on the use of Sodium polystyrene sulfonate in patients with hepatic impairment.

### Females of Reproductive Potential and Males
There is no FDA guidance on the use of Sodium polystyrene sulfonate in women of reproductive potentials and males.

### Immunocompromised Patients
There is no FDA guidance one the use of Sodium polystyrene sulfonate in patients who are immunocompromised.

# Administration and Monitoring

### Administration
- Oral.
- Rectal.

### Monitoring
- Patients receiving sodium polystyrene sulfonate should be monitored for all applicable electrolyte disturbances.

# IV Compatibility
- There is limited information regarding IV Compatibility.

# Overdosage
- Biochemical disturbances resulting from overdosage may give rise to clinical signs and symptoms of hypokalemia, including: irritability, confusion, delayed thought processes, muscle weakness, hyporeflexia, which may progress into frank paralysis and/or apnea.
- Electrocardiographic changes may be consistent with hypokalemia or hypercalcemia; cardiac arrhythmias may occur. Appropriate measures should be taken to correct serum electrolytes (potassium, calcium), and the resin should be removed from the alimentary tract by appropriate use of laxatives or enemas.

# Pharmacology

## Mechanism of Action
- As the resin passes along the intestine or is retained in the colon after administration by enema, the sodium ions are partially released and are replaced by potassium ions. For the most part, this action occurs in the large intestine, which excretes potassium ions to a greater degree than does the small intestine. The efficiency of this process is limited and unpredictably variable. It commonly approximates the order of 33%, but the range is so large that definitive indices of electrolyte balance must be clearly monitored.

## Structure
- Kionex(Sodium Polystyrene Sulfonate Suspension USP) can be administered orally or in an enema. It is a raspberry-flavored suspension containing 15 grams of cation-exchange resin (Sodium Polystyrene Sulfonate USP); 21.5 mL of Sorbitol Solution USP (equivalent to approximately 19.3 grams of Sorbitol); 0.12 mL (0.2%) of Alcohol per 60 mL of suspension. Also contains Purified Water USP, Propylene Glycol USP, Magnesium Aluminum Silicate NF, Xanthan Gum NF, Sodium Saccharin USP, Sorbic Acid NF, Methylparaben NF, Propylparaben NF, and flavor.
- Sodium polystyrene sulfonate is a benzene, diethenyl-, polymer with ethenylbenzene, sulfonated, sodium salt and has the following structural formula:
- The sodium content of the suspension is 1500 mg (65 mEq) per 60 mL. It is a brown, slightly viscous suspension with an in vitro exchange capacity of approximately 3.1 mEq (in vivo approximately 1 mEq) of potassium per 4 mL (1 gram) of suspension. It can be administered orally or in an enema.

## Pharmacodynamics
- There is limited information regarding pharmacodynamics.

## Pharmacokinetics
- There is limited information regarding pharmacokinetics.

## Nonclinical Toxicology

### Carcinogenesis, Mutagenesis, Impairment of Fertility
- Studies have not been performed.

# Clinical Studies
- There is limited information regarding Clinical Studies.

# How Supplied
- KionexSuspension is a light brown, raspberry-flavored suspension supplied in pint (473 mL) bottles (NDC 0574-2002-16) and 60 mL unit dose bottles (NDC 0574-2002-02).
- Dispense in a tight container, as defined in the USP. If repackaging into other containers, store in refrigerator and use within 14 days of packaging.
- SHAKE WELL BEFORE USING.

## Storage
- Store at 20 to 25 C (68 to 77 F) 

# Images

## Drug Images

## Package and Label Display Panel

# Patient Counseling Information
- There is limited information regarding Patient Counseling Information.

# Precautions with Alcohol
- Alcohol-Sodium polystyrene sulfonate interaction has not been established. Talk to your doctor about the effects of taking alcohol with this medication.

# Brand Names
- KIONEX

# Look-Alike Drug Names
- There is limited information regarding Look-Alike Drug Names.

# Drug Shortage Status

# Price