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  • 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

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



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

ECG Findings


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)

  • Pts are likely dehydrated and require saline hydration as initial therapy


  • 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 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


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
  • Caution in renal failure, though bisphosphonates have been safely used in pts with pre-existing renal failure[2]

Electrolyte Repletion


  • Furosemide is NOT routinely recommended
  • Only consider in patients with renal insufficiency or heart failure and volume overload


Consider if patient:

  • Anuric with Renal Failure
  • Failing all other therapy
  • Severe hypervolemia not amenable to diuresis
  • Serum Calcium level >18mg/dL


Decrease Ca mobilization from bone and are helpful with steroid-sensitive tumors (e.g. lymphoma, MM)


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

See Also


  1. 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.
  2. LeGrand SB et al. Narrative Review: Furosemide for Hypercalcemia: An Unproven yet Common Practice. Ann Intern Med. 2008;149:259-263.