Hypercalcemia: Difference between revisions
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*High >10.5 meq/L (>2.7 ionized) | *High >10.5 meq/L (>2.7 ionized) | ||
*High! >12.0 meq/L | *High! >12.0 meq/L | ||
*90% of cases | *90% of cases associated with malignancy or hyperparathyroidism | ||
*Symptoms most correlated | *Symptoms most correlated with rate of rise of Ca, not absolute level | ||
==Clinical Features== | ==Clinical Features== | ||
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{{Hypercalcemia DDX}} | {{Hypercalcemia DDX}} | ||
== | ==Evaluation== | ||
===Work-Up=== | ===Work-Up=== | ||
*Calcium | *Calcium | ||
*Phosphate | *Phosphate, Magnesium | ||
*PTH | |||
*Lipase | *Lipase | ||
* | *[[Urinalysis]] | ||
*ECG | *[[ECG]] | ||
*Ionized Ca | *Ionized Ca | ||
===ECG Findings=== | ===[[ECG]] Findings=== | ||
*Prolonged PR & QRS | *Prolonged PR & QRS | ||
*Widened T waves | *Widened T waves | ||
* | *[[bradycardia|Bradyarrhythmia]]s / [[heart block]] | ||
*[[Short QT]] | *[[Short QT]] | ||
*STE/STD, can mimic [[Myocardial Infarction]]<ref>Littmann L, Taylor L 3rd, Brearley WD Jr. ST-segment elevation: a common finding in severe hypercalcemia. J Electrocardiol. 2007 Jan;40(1):60-2.</ref> | |||
== | ==Management== | ||
{{Hypercalcemia treatment}} | {{Hypercalcemia treatment}} | ||
==Disposition== | ==Disposition== | ||
{| {{table}} | |||
| align="center" style="background:#f0f0f0;"|'''Calcium''' | |||
| align="center" style="background:#f0f0f0;"|'''Disposition''' | |||
|- | |||
| <12||Home with follow up | |||
|- | |||
* | | 12-14||Depends | ||
|- | |||
| >14|| | |||
*No [[ECG]] changes: Admit ward | |||
*[[ECG]] changes: Admit telemetry | |||
|} | |||
==See Also== | ==See Also== | ||
*[[Hypercalcemia of Malignancy]] | *[[Hypercalcemia of Malignancy]] | ||
==References == | ==References== | ||
<references/> | <references/> | ||
[[Category:FEN]] | [[Category:FEN]] |
Revision as of 14:30, 19 October 2019
Background
- High >10.5 meq/L (>2.7 ionized)
- High! >12.0 meq/L
- 90% of cases associated with malignancy or hyperparathyroidism
- Symptoms most correlated with rate of rise of Ca, not absolute level
Clinical Features
Symptoms of hypercalcemia
Mnemonic: Stones, Bones, Groans, Moans, Thrones, Psychic Overtones
- "Stones"
- "Bones"
- Bone pain/destruction
- "Groans"
- "Thrones"
- Polyuria/polydipsia (Renal insufficiency)
- Constipation
- "Psychic Overtones"
Differential Diagnosis
Causes of Hypercalcemia
- Addison's disease
- Calciphylaxis
- Excess vitamin D
- Hypercalcemia of malignancy
- Hyperparathyroidism
- Hyperthyroidism
- Hypothyroidism
- Lithium
- Milk-alkali syndrome
- Paget disease
- Sarcoidosis
- Thiazide diuretics
Evaluation
Work-Up
- Calcium
- Phosphate, Magnesium
- PTH
- Lipase
- Urinalysis
- ECG
- Ionized Ca
ECG Findings
- Prolonged PR & QRS
- Widened T waves
- Bradyarrhythmias / heart block
- Short QT
- STE/STD, can mimic Myocardial Infarction[1]
Management
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 likely 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)
- Tachyphylaxis limits use long term, but is a great choice for emergent cases
Bisphosphonates
Give for severe hypercalcemia due to excessive bone resorption (lowers Ca within 12-48hr)[≥12 mg/dL][≥3 mmol/L][2]
- Pamidronate 90mg IV over 24 hours OR
- Zoledronate 4mg IV over 15 minutes
- Caution in renal failure, though bisphosphonates have been safely used in pts with pre-existing renal failure[3]
Electrolyte Repletion
- Correct hypokalemia
- Correct hypomagnesemia
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
- Neurologic symptoms
- Heart failure with reduced ejection fraction (unable to provide fluids)
Corticosteroids
Decrease Ca mobilization from bone and are helpful with steroid-sensitive tumors (e.g. lymphoma, MM)
- Prednisone 60mg PO daily
Disposition
Calcium | Disposition |
<12 | Home with follow up |
12-14 | Depends |
>14 |
See Also
References
- ↑ Littmann L, Taylor L 3rd, Brearley WD Jr. ST-segment elevation: a common finding in severe hypercalcemia. J Electrocardiol. 2007 Jan;40(1):60-2.
- ↑ Shane et al. Uptodate: Treatment of Hypercalcemia. https://www.uptodate.com/contents/treatment-of-hypercalcemia#disclaimerContent
- ↑ LeGrand SB et al. Narrative Review: Furosemide for Hypercalcemia: An Unproven yet Common Practice. Ann Intern Med. 2008;149:259-263.