Hypercalcemia: Difference between revisions
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==Treatment==
==Treatment==
#Treatment based on calcium level
===Asymptomatic or Ca <12 mg/dL===
##Asymptomatic or mildly symptomatic hypercalcemia (Ca <12)
*Does not require immediate treatment
###Does not require immediate treatment
*Advise to avoid factors that can aggravate hypercalcemia (thiazide diuretics, Li, volume depletion, prolonged inactivity, high Ca diet)
###Advise to avoid factors that can aggravate hypercalcemia (thiazide diuretics, Li, volume depletion, prolonged inactivity, high Ca diet)
===Mildly symptomatic Ca 12-14 mg/dL===
##Asymptomatic or mildly symptomatic w/ chronic moderate hypercalcemia (Ca between 12-14)
*May not require immediate therapy; however, an acute rise may cause symptoms necessitating treatment as described for severe hypercalcemia (see below)
###May not require immediate therapy; however, an acute rise may cause symptoms necessitating treatment as desdcribed for severe hypercalcemia (see below)
===Symptomatic or Severe hypercalcemia (Ca >14 mg/dL)===
##Severe hypercalcemia (Ca >14) or symptomatic hypercalcemia are usually dehydrated and require saline hydration as initial therapy
Patients are dehydrated and require saline hydration as initial therapy
###Consider isotonic saline at 200-300 mL/hour; adjust to maintain urine output at 100-150 mL/hour
====Hydration====
###Consider adding calcitonin 4 units/kg SC or IV q12hr in pts w/ Ca >14 mg/dL (3.5 mmol/L) who are also symptomatic (lowers Ca w/in 2-4hr)
*Isotonic saline at 200-300 mL/hour; adjust to maintain urine output at 100-150 mL/hour
####Lowers Ca within 2-4hr
====Calcitonin====
###Bisphosphonates
*Consider adding calcitonin 4 units/kg SC or IV q12hr in patients w/ Ca >14 mg/dL (3.5 mmol/L) who are also symptomatic (lowers Ca w/in 2-4hr)
####Give for severe hypercalcemia due to excessive bone resorption (lowers Ca within 12-48hr)
====Bisphosphonates====
####Pamidronate 90mg IV over 24 hours
Give for severe hypercalcemia due to excessive bone resorption (lowers Ca within 12-48hr)
####Zoledronate 4mg IV over 15 minutes
*Pamidronate 90mg IV over 24 hours OR
#Electrolyte Repletion
*Zoledronate 4mg IV over 15 minutes
##Correct hypokalemia
====Electrolyte Repletion====
##Correct hypomagnesemia
*Correct [[hypokalemia]]
#Furosemide is NOT routinely recommended
*Correct [[hypomagnesemia]]
##Consider in pts w/ renal insufficiency or heart failure to prevent fluid overload
====Diuresis====
#Dialysis if:
*Furosemide is NOT routinely recommended
##Anuric
*Only consider in patients with renal insufficiency or heart failure and volume overload
##ARF
====Dialysis====
##CHF
Consider if patient:
##Calcium level >18
*Anuric with Renal Failure
#Decrease Ca mobilization from bone
*Failing all other therapy
##Corticosteroids
*Severe hypervolemia not amenable to diuresis
###Prednisone 60mg PO qd
*Serum Calcium level >18mg/dL
###Helpful w/ steroid-sensitive tumors (e.g. lymphoma, MM)
====Corticosteroids====
Decrease Ca mobilization from bone and are helpful w/ steroid-sensitive tumors (e.g. lymphoma, MM)
*Prednisone 60mg PO daily


==See Also==
==See Also==

Revision as of 00:41, 25 June 2015

Background

  • High >10.5 meq/L (>2.7 ionized)
  • High! >12.0 meq/L
  • 90% of cases assoc w/ malignancy or hyperparathyroidism
  • Symptoms most correlated w/ rate of rise of Ca, not absolute level

Clinical Features

Mnemonic: Stones, Bones, Groans, Moans, Thrones, Psychic Overtones

Stones

  1. Renal calculi

Bones

  1. Bone pain/destruction

Groans

  1. Abdominal pain and vomiting
  2. Dehydration

Thrones

  1. Polyuria/polydipsia (Renal insufficiency)
  2. Constipation

Psychic Overtones

  1. Lethargy/confusion/Hallucinations

Diagnosis

  1. ECG
    1. Prolonged PR & QRS
    2. Shortened QT
    3. Depressed ST
    4. Widened T waves
    5. Bradyarrhythmias / heart block

Work-Up

  1. Calcium
  2. Phosphate
  3. Lipase
  4. UA
  5. ECG

Differential Diagnosis

  • Malignancy
  • Hyperparathyroidism
  • Lithium
  • Thiazides
  • Hypothyroidism
  • Addison's
  • Paget's
  • Sarcoid
  • Hyperthyroid
  • Milk-alkali syndrome
  • Excess vit D
  • Calciphylaxis

Treatment

Asymptomatic or Ca <12 mg/dL

  • Does not require immediate treatment
  • Advise to avoid factors that can aggravate hypercalcemia (thiazide diuretics, Li, volume depletion, prolonged inactivity, high Ca diet)

Mildly symptomatic Ca 12-14 mg/dL

  • May not require immediate therapy; however, an acute rise may cause symptoms necessitating treatment as described for severe hypercalcemia (see below)

Symptomatic or Severe hypercalcemia (Ca >14 mg/dL)

Patients are dehydrated and require saline hydration as initial therapy

Hydration

  • Isotonic saline at 200-300 mL/hour; adjust to maintain urine output at 100-150 mL/hour

Calcitonin

  • Consider adding calcitonin 4 units/kg SC or IV q12hr in patients w/ Ca >14 mg/dL (3.5 mmol/L) who are also symptomatic (lowers Ca w/in 2-4hr)

Bisphosphonates

Give for severe hypercalcemia due to excessive bone resorption (lowers Ca within 12-48hr)

  • Pamidronate 90mg IV over 24 hours OR
  • Zoledronate 4mg IV over 15 minutes

Electrolyte Repletion

Diuresis

  • Furosemide is NOT routinely recommended
  • Only consider in patients with renal insufficiency or heart failure and volume overload

Dialysis

Consider if patient:

  • Anuric with Renal Failure
  • Failing all other therapy
  • Severe hypervolemia not amenable to diuresis
  • Serum Calcium level >18mg/dL

Corticosteroids

Decrease Ca mobilization from bone and are helpful w/ steroid-sensitive tumors (e.g. lymphoma, MM)

  • Prednisone 60mg PO daily

See Also

Source

  • Tintinalli
  • Uptodate
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