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