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| ==Background== | | ==Background== |
| 4 categories:
| | #Causes: |
| #Local osteolysis associated primarily with bone mets (20%) | | ##PTHrP release |
| ##Breast, MM, lymphoma
| | ###SCC (particularly of the head and neck), breast renal, endometrial cancer |
| #PTHrP release | | ##Local osteolysis |
| ##Squamous cell carcinoma (particularly of the head and neck); renal, endometrial, and breast cancers, HTLV-lymphoma | | ###Associated primarily with bone mets |
| #Lymphoma-associated secretion of calcitriol (increases intestinal ca absorption and bone resorption by osteoclasts (1%) | | ###Multiple myeloma, lung, breast cancer |
| ##Hodgkin-associated hypercalcemia and 30% to 40% of non-Hodgkin lymphoma–associated hypercalcemia | | ##Production of vitamin D analogues |
| # Ectopic secretion of PTH, which is extremely rare (usually with parathyroid carcinomas) | | ###Lymphoma (Hodgkin) |
| ##ovary, lung, and primitive neuroectoderm | |
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| ==Diagnosis== | | ==Clinical Features== |
| Signs & Symptoms
| | #See [[Hypercalcemia]] |
| #Consistent with degree of hypercalcemia and rate of increase (see Hypercalcemia) | |
| #Polydipsia, polyuria
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| #Bone pain
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| #Gastrointestinal symptoms (anorexia, nausea, vomiting, and constipation)
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| #Psychiatric symptoms (memory loss, apathy)
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| #Lethargy, and fatigue
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| #Bony tenderness over sites of osteolysis
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| #Dehydration
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| #Look for signs of CHF, renal failure to avoid vol overload
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| ==Work-Up== | | ==Work-Up== |
| #Chem10 | | #Chem10 |
| #ionized Ca | | #Ionized Ca |
| #CBC | | #CBC |
| #LFTs (alk phos, albumin) | | #LFTs (alk phos, albumin) |
| #PTH | | #ECG |
| #PTH-rP (non emergent)
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| #EKG (prolonged PR interval, widened QRS complex, shortened QT interval, bundle branch block, or bradydysrhythmia and even cardiac arrest (typically with calcium levels > 15 mg/dL)
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| ===Categorization===
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| #Mild (total calcium level, 10.5-11.9 mg/dL)
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| #Moderate (total calcium level, 12.0-13.9 mg/dL)
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| #Severe (total calcium level ≥ 14.0 mg/dL)
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| ==Treatment== | | ==Treatment== |
| Address volume losses and reduce bone resorption
| | #See [[Hypercalcemia]] |
| | |
| ===Calcium level < 12 mg/dL (mild or chronic)===
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| #Oral hydration | |
| #High-salt diet
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| #Avoid medications that cause hypercalcemia
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| #No treatment at all may be an option
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| ===Calcium level ≥ 12 mg/dL (severe or symptomatic)===
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| #Normal saline
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| ##initially 200-300 mL/h until patient is euvolemic
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| ##then adjust to maintain urine output of 100-150 mL/h
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| #IV Bisphosphonate (pyrophosphate analogues bind to hydroxyapatite and inhibit bone crystal dissolution and therefore osteoclastic resorption)
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| ##Zoledronic acid: 4 mg over 15 minutes; 8 mg if second dose is required (not FDA approved)
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| ##Pamidronate: given over 2-24 hours, either as 60 mg (calcium level, 12-13.5 mg/dL) or 90 mg (calcium level >13.5 mg/dL)
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| ##Calcium levels begin to decrease 2 to 4 days after administration of IV bisphosphonates, reach a nadir between 4 and 7 days, and typically remain within the reference range for 1 to 4 weeks
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| ##In a head-to-head comparison of zoledronate (4 mg) versus pamidronate (90 mg), zoledronate had the benefit of a shorter administration time (15 minutes vs 2 hours, respectively) and a statistically significant difference (p 0.001) of 0.7 mg/dL in the calcium level at its nadir (9.8 mg/dL vs 10.5 mg/dL, respectively)
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| #Calcitonin 4 IU/kg SQ or IM; repeat every 6-12 hours only if patient is responsive
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| ##Calcitonin exerts this effect by inhibiting osteoclastic resorption and inducing calciuresis
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| ##peak activity within 12-24h
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| ##lowers Ca ~1.0mg/dL
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| #Loop diuretics only after volume repletion in patients with congestive heart failure or chronic kidney disease
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| #Hemodialysis for patients with any of the following:
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| ##Neurologic symptoms
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| ##Calcium level ≥ 18 mg/dL
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| ##Acute or chronic kidney disease (GFR < 10-20 mL/min)
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| ##Congestive heart failure
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| ==Disposition== | | ==Disposition== |
| #Ca <12: home with f/u after d/w onc | | #Ca <12 |
| #Ca>12: admit ward | | ##Home with f/u if oncology concurs |
| #EKG changes: tele | | #Ca>12 |
| | ##Admit ward |
| | #ECG changes |
| | ##Admit telemetry |
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| ==See Also== | | ==See Also== |
| Hypercalcemia | | [[Hypercalcemia]] |
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| ==Source== | | ==Source== |
| EM Practice 3/10 | | *EM Practice 3/10 |
| | *Tintinalli |
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| [[Category:FEN]] | | [[Category:FEN]] |
| [[Category:Heme/Onc]] | | [[Category:Heme/Onc]] |
