Hypercalcemia
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
- Renal calculi
Bones
- Bone pain/destruction
Groans
- Abdominal pain and vomiting
- Dehydration
Thrones
- Polyuria/polydipsia (Renal insufficiency)
- Constipation
Psychic Overtones
- Lethargy/confusion/Hallucinations
Diagnosis
- ECG
- Prolonged PR & QRS
- Shortened QT
- Depressed ST
- Widened T waves
- Bradyarrhythmias / heart block
Work-Up
- Calcium
- Phosphate
- Lipase
- UA
- ECG
Differential Diagnosis
- Malignancy
- Hyperparathyroidism
- Lithium
- Thiazides
- Hypothyroidism
- Addison's
- Paget's
- Sarcoid
- Hyperthyroid
- Milk-alkali syndrome
- Excess vit D
- Calciphylaxis
Treatment
- Treatment based on calcium level
- Asymptomatic or mildly symptomatic hypercalcemia (Ca <12)
- Does not require immediate treatment
- Advise to avoid factors that can aggravate hypercalcemia (thiazide diuretics, Li, volume depletion, prolonged inactivity, high Ca diet)
- 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 desdcribed for severe hypercalcemia (see below)
- Severe hypercalcemia (Ca >14) or symptomatic hypercalcemia are usually 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
- 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)
- Lowers Ca within 2-4hr
- Bisphosphonates
- Give for severe hypercalcemia due to excessive bone resorption (lowers Ca within 12-48hr)
- Pamidronate 90mg IV over 24 hours
- Zoledronate 4mg IV over 15 minutes
- Asymptomatic or mildly symptomatic hypercalcemia (Ca <12)
- Electrolyte Repletion
- Correct hypokalemia
- Correct hypomagnesemia
- Furosemide is NOT routinely recommended
- Consider in pts w/ renal insufficiency or heart failure to prevent fluid overload
- Dialysis if:
- Anuric
- ARF
- CHF
- Calcium level >18
- Decrease Ca mobilization from bone
- Corticosteroids
- Prednisone 60mg PO qd
- Helpful w/ steroid-sensitive tumors (e.g. lymphoma, MM)
- Corticosteroids
See Also
Source
- Tintinalli
- Uptodate