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 assoc w/ malignancy or hyperparathyroidism
*80% of cases associated with malignancy (most common among inpatients) or hyperparathyroidism (most common among outpatients)<ref>Pfennig CL, Slovis CM. Electrolyte disorders. In: Walls RM, Hockberger RS, Gausche-Hill M, et al., eds. Rosen’s Emergency Medicine: Concepts and Clinical Practice. 9th ed. Saunders; 2018:(Ch) 117.</ref>
*Symptoms most correlated w/ rate of rise of Ca, not absolute level
*Symptoms most correlated with rate of rise of Ca, not absolute level


==Clinical Features==
==Clinical Features==
Mnemonic: Stones, Bones, Groans, Moans, Thrones, Psychic Overtones 
{{Hypercalcemia clinical features}}
===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==
==Differential Diagnosis==
#ECG
{{Hypercalcemia DDX}}
##Prolonged PR & QRS
 
##Shortened QT
==Evaluation==
##Depressed ST
===Work-Up===
##Widened T waves
*Calcium
##Bradyarrhythmias / heart block
*Phosphate, Magnesium
*PTH
*Lipase
*[[Urinalysis]]
*[[ECG]]
*Ionized Ca
 
===[[ECG]] Findings===
*Prolonged PR & QRS
*Widened T waves
*[[bradycardia|Bradyarrhythmia]]s / [[heart block]]
*[[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><ref>Donovan J, Jackson M. Hypercalcaemia Mimicking STEMI on Electrocardiography. Case Rep Med. 2010;2010:563572. doi:10.1155/2010/563572</ref>
 
==Management==
{{Hypercalcemia treatment}}


==Work-Up==
#Calcium
#Phosphate
#Lipase
#UA
#ECG


==Differential Diagnosis==
==Medication Dosing==
*Malignancy
{{MedicationDose
*Hyperparathyroidism
| drug = Calcitonin
*Lithium
| dose = 4 units/kg q12hr
*Thiazides
| route = SC or IV
*Hypothyroidism
| context = Symptomatic or severe hypercalcemia (Ca >14 mg/dL)
*Addison's
| indication = Hypercalcemia
*Paget's
| population = Adult
*Sarcoid
| notes = Onset 2-4 hours; tachyphylaxis limits long-term use
*[[Hyperthyroid]]
}}
*Milk-alkali syndrome
{{MedicationDose
*Excess vit D
| drug = Prednisone
*[[Calciphylaxis]]
| dose = 60mg daily
| route = PO
| context = Steroid-sensitive tumors (lymphoma, multiple myeloma)
| indication = Hypercalcemia
| population = Adult
}}
 
==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
|}


==Treatment==
== Calculators ==
===Asymptomatic or Ca <12 mg/dL===
{{Corrected_Calcium_Calculator}}
*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====
*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
====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==
*[[Hypercalcemia of Malignancy]]
*[[Hypercalcemia of Malignancy]]


==Source ==
==References==
*Tintinalli
<references/>
*Uptodate


[[Category:FEN]]
[[Category:FEN]]

Latest revision as of 16:31, 21 March 2026

Background

  • High >10.5 meq/L (>2.7 ionized)
  • High! >12.0 meq/L
  • 80% of cases associated with malignancy (most common among inpatients) or hyperparathyroidism (most common among outpatients)[1]
  • 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

Differential Diagnosis

Causes of Hypercalcemia

Evaluation

Work-Up

  • Calcium
  • Phosphate, Magnesium
  • PTH
  • Lipase
  • Urinalysis
  • ECG
  • Ionized Ca

ECG Findings

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][4]

  • 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[5]

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
  • 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)


Medication Dosing

Calcitonin 4 units/kg q12hr SC or IV — Onset 2-4 hours; tachyphylaxis limits long-term use Prednisone 60mg daily PO

Disposition

Calcium Disposition
<12 Home with follow up
12-14 Depends
>14
  • No ECG changes: Admit ward
  • ECG changes: Admit telemetry

Calculators

Corrected Calcium

Corrected Calcium for Hypoalbuminemia
Parameter Value
Serum Calcium (mg/dL)
Serum Albumin (g/dL)
Corrected Calcium mg/dL
Interpretation
8.5–10.5 Normal corrected calcium range.
<8.5 Hypocalcemia — Consider IV calcium if symptomatic.
>10.5 Hypercalcemia — Investigate underlying cause; consider IV fluids.
References
  • Formula: Corrected Ca = Measured Ca + 0.8 × (4.0 – Albumin)
  • Payne RB, et al. Interpretation of serum calcium in patients with abnormal serum proteins. BMJ. 1973;4(5893):643-646. PMID 4758544.

See Also

References

  1. ↑ Pfennig CL, Slovis CM. Electrolyte disorders. In: Walls RM, Hockberger RS, Gausche-Hill M, et al., eds. Rosen’s Emergency Medicine: Concepts and Clinical Practice. 9th ed. Saunders; 2018:(Ch) 117.
  2. ↑ 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.
  3. ↑ Donovan J, Jackson M. Hypercalcaemia Mimicking STEMI on Electrocardiography. Case Rep Med. 2010;2010:563572. doi:10.1155/2010/563572
  4. ↑ Shane et al. Uptodate: Treatment of Hypercalcemia. https://www.uptodate.com/contents/treatment-of-hypercalcemia#disclaimerContent
  5. ↑ LeGrand SB et al. Narrative Review: Furosemide for Hypercalcemia: An Unproven yet Common Practice. Ann Intern Med. 2008;149:259-263.
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