This document discusses hypercalcemia, which is defined as a serum calcium level above 10.5 mg/dl. It outlines the causes of hypercalcemia including primary hyperparathyroidism, certain cancers, and excessive vitamin D or calcium supplementation. Signs and symptoms are noted such as abdominal pain, nausea, weakness and cardiac issues. Diagnostic testing including PTH, calcium, and phosphate levels as well as imaging are covered. Treatment focuses on rehydration, bisphosphonates, glucocorticoids, calcitonin, surgery if needed, and addressing the underlying cause. Complications of untreated hypercalcemia include osteoporosis, kidney stones, and kidney failure.

1. HYPERCALCEMIA
ANEELA PASHA
Final year
Clinical Pharmacy.

2. HYPERCALCEMIA
• Serum calcium > 10.5 mg/dl
• Mild: total CA : 10.5-11.9 mg/dl
• Moderate: total CA : 12-13.9 mg/dl
• Severe: total CA: 14-16 mg/dl
• Calcium enters extra cellular fluid from intestine
and bone and excreted through kidney.
• Calcium is tightly controlled by hormones (PTH,
calcitriol , calcitonin).

3. CALCIUM and its three forms
• Ionized (physiological form) (40%)
• Protein bound (50%), mainly to albumin
• Non ionized or Complexes to citrate
and phosphate (10%)

4. CALCIUM
ECF
8.5-10.6 mg/dl
2.25-2.65 nmol/l
ICF
CYTOPLASMIC FREE
50-100 nmol/l
PROTIEN
BOUND
45%
DIFFUSIBLE
ULTRAFILTRABLE
55%
90%
ALBUMIN
10%
GLOBULUIN
IONIZED
45%
COMPLEXED
10%

5. FUNCTIONS
• Muscle contraction
• Neuromuscular/ nerve conduction
• Intracellular signaling
• Bone formation
• Coagulation
• Enzyme regulation

6. VITAMIN D

7. Causes of hypercalcemia
Endocrine:
• Hyperparathyroidism
• MEN Type 1 (parathyroid adenoma , pituitary adenoma , pancreatic islet cell tumor)
• Familial hypocalciuric hypercalcemia
Malignancy:
• Metastases
• PTHrP
• Breast caner, lung cancer , bone cancer.
Granulomatous Disease:
• Sarcoidosis
• TB
Miscellaneous:
• Acute kidney failure
• Milk-alkali syndrome
Medications:
• Lithium therapy
• Thiazides ( inc. Na, water absorp and inc ca concentration)
• Vit D

8. Causes of hypercalcemia
C calcium supplements
H hyperparathyroidism
I immobilization
M MEN, milk-alkali syndrome,
medication
P parathyroid hyperplasia or
adenoma
A alcohol
N neoplasm (breast, lung,
kidney)
Z Zollinger ellison syndrome
E excessive vit D
E excessive vit A
S Sarcoidosis

9. THYROTOXICOSIS
• Sever thyrotoxicosis
• Increased calcium release from bone
(thyroxine acts on bone)
• PTH is normal
• Takes 4-6 weeks to resolve with antithyroid
treatment

10. Clinical presentation
• The famous mnemonic ;
• Stone
• Bones
• Abdominal moans
• thrones
• Psychic groans
• Others: anorexia, n/v , weakness, renal failure cardiac
arrest , stupor or coma .
• Hypocalcaemia can increase gastrin production,
leading to increased acidity so peptic ulcer may also
occur.

11. INVESTIGATIONS
• History
• Examination
• ECG
• Blood levels.

12. INVESTIGATIONS
• History + PTH levels are essential for
diagnosis.
• Blood tests: calcium, phosphate, magnesium,
creatinine, U&E, PTH.
• CXR (bones ,lungs etc. )
• CT scan / MRI
• Mammogram
• ECG = short QT interval

13. MANAGEMENT
• Persistent
high levels of
calcium.

14. MANAGEMENT
• Acute management focuses on hydration the
other medications
• Chronic management focuses on the
underlying etiology.
• Hypercalcemia crisis = aggressive TX

15. MANAGEMENT
• Rehydration:
Intravenous 0.9% saline 4-6 litres in 24h
• Monitor for fluid overload if renal impairment
or elderly.
• Loop diuretics rarely used and only if fluid
overload develops; not effective for reducing
serum calcium
• furosemide 40mg/12h PO/IV.

16. MANAGEMENT
• After rehydration: intravenous bisphosphonates
(inhibits osteoclast. )
Zoledronic acid 4mg over 15 mins
Or Pamidronate 30 to 90mg (depending on severity of hypocalcaemia) at
20mg/hr
Or Ibandronic acid 2 to 4mg
• Give more slowly and consider dose reduction in renal impairment
• Monitor serum calcium response -after at 2 to 4 days
• Can cause hypocalcaemia if vitamin D deficiency or suppressed PTH
• Max effects in 1W.

17. MANAGEMENT
• Second line treatments:
• Glucocorticoids (inhibit VIT D production)
• In lymphoma, other granulomatous diseases
or Vit D poisoning, sarcoidosis.
• Prednisolone 20-40mg daily
• Usually effective in 2 to 4 days

18. MANAGEMENT
• Calcitonin :
• Can be considered if poor response to
Bisphosphonates
• Dose 4U/kg S/C or IM 12h
• Calcimimetics :
• Licensed for hypocalcaemia due to primary
hyperparathyroidism, parathyroid carcinoma or
renal failure.
• only cinacalcet is currently available

19. • DIALYSIS
• In cases life-threatening hypercalcemia,
dialysis to get rid your blood of extra calcium
and waste and lowering serum calcium levels.
• Only when other treatment methods not
works.

20. MANAGEMENT
• SURGERY
• Parathyroidectomy
• Can be considered in acute presentation of
primary hyperparathyroidism if severe
hypercalcaemia and poor response to other
measures.
• Chemotherapy in malignancy.

21. LIFESTYLE CHANGES
• Healthier lifestyle
• Drink plenty of water
• Exercise .

22. Complications (if untreated)
• Osteoporosis
• Kidney stones
• Kidney failure
• Nervous system dysfunction
• Arrhythmia
• Cardiac arrest

23. REFERENCE
• Society for Endocrinology, Endocrine guidance.
• Kumar and Clark medicine 2009
• Emedicine.medscape.com
• Dipiro Pharmacotherapy Handbook 8th Edition
• (Pg. 988-989)