Hypercalcemia

Background

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

Clinical Features

1. Stones
   1. Renal calculi
2. Bones
   1. Bone pain/destruction
3. Groans
   1. Abd pain, N/V, constipation
4. Moans
   1. Lethargy/confusion
5. Also:
   1. Polyuria/polydipsia
   2. Dehydration
   3. Renal insufficiency

Diagnosis

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

Work-Up

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

DDX

1. Malignancy
2. Hyperparathyroidism
3. Lithium
4. Thiazides
5. Hypothyroidism
6. Addison's
7. Paget's
8. Sarcoid
9. Hyperthyroid
10. Milk-alkali synd
11. Excess vit D

Treatment

Emergency Department

1. Volume repletion
   1. Goal UOP = 500cc/hr
   2. Start NS @ 250-500cc/hr until pt is euvolemic; then decrease to 100-150cc/hr
2. Correct hypokalemia
3. Correct hypomagnesemia
4. Furosemide is NOT recommended
5. Dialysis if:
   1. Anuric
   2. ARF
   3. CHF
   4. Calcium level >18

Inpatient

1. Decrease Ca mobilization from bone
   1. Calcitonin
      1. 4 units/kg SC or IV q12hr
      2. Lowers Ca within 2-4hr
   2. Corticosteroids
      1. Prednisone 60mg PO qd
      2. Helpful w/ steroid-sensitive tmors (e.g. lymphoma, MM)
   3. Bisphosphonates
      1. Lowers Ca within 12-48hr
      2. Pamidronate 90mg IV over 24 hours
   4. Zoledronate 4mg IV over 15 minutes

See Also

Hypercalcemia of Malignancy

Source

Tintinalli