Name = PAGENAME
DiseasesDB = 6196
ICD10 = ICD10|E|83|5|e|70
ICD9 = ICD9|275.42
MedlinePlus = 000365
eMedicineSubj = med
eMedicineTopic = 1068
eMedicine_mult = eMedicine2|emerg|260 eMedicine2|ped|1062
MeshID = D006934
American English[http://cougar.eb.com/soundc11/h/hyperc01.wav Hypercalcemia] ) is an elevated calcium level in the blood. (Normal range: 9-10.5 mg/dL or 2.2-2.6 mmol/L). It can be an asymptomatic laboratory finding, but because an elevated calcium level is often indicative of other diseases, a diagnosis should be undertaken if it persists. It can be due to excessive skeletal calcium release, increased intestinal calcium absorption, or decreased renal calcium excretion.
igns and symptoms
Hypercalcemia "per se" can result in fatigue, depression,
confusion, anorexia, nausea, vomiting, constipation, pancreatitisor increased urination "Bones, stones, groans, and psychiatric overtones" is a saying which will help you remember the signs and symptoms of hypercalcemia; if it is chronic it can result in urinary calculi (renal stones or bladder stones). Abnormal heart rhythms can result, and EKGfindings of a short QT intervaland a widened T wave suggest hypercalcemia.
Symptoms are more common at high calcium
blood values(12.0 mg/dL or 3 mmol/l). Severe hypercalcemia (above 15-16 mg/dL or 3.75-4 mmol/l) is considered a medical emergency: at these levels, comaand cardiac arrestcan result.
*"hyperparathyroidism and malignancy account for ~90% of cases"
solitary parathyroid adenoma
primary parathyroid hyperplasia
multiple endocrine neoplasia(MEN)
familial isolated hyperparathyroidism(OMIM|146200)
familial hypocalciuric hypercalcemia/ familial benign hypercalcaemia(OMIM|145980, OMIM|145981, OMIM|600740)
**solid tumor with metastasis (e.g.
breast canceror classically squamous cell carcinoma, which can be PTHrP-mediated)
**solid tumor with humoral mediation of hypercalcemia (e.g. lung or kidney cancer,
hematologic malignancy( multiple myeloma, lymphoma, leukemia)
vitamin-D metabolic disorders
hypervitaminosis D(vitamin D intoxication)
**elevated 1,25(OH)2D (see calcitriol under
Vitamin D) levels (e.g. sarcoidosisand other granulomatous diseases)
idiopathic hypercalcemia of infancy(OMIM|143880)
**rebound hypercalcemia after
*disorders related to high bone-turnover rates
Paget's disease of the bone
The goal of therapy is to treat the hypercalcemia first and subsequently effort is directed to treat the underlying cause.
Initial therapy: fluids and diuretics
*hydration, increasing salt intake, and
**hydration is needed because many patients are dehydrated due to vomiting or renal defects in concentrating urine.
**increased salt intake also can increase body fluid volume as well as increasing urine sodium excretion, which further increases urinary calcium excretion (In other words, calcium and sodium (salt) are handled in a similar way by the kidney. Anything that causes increased sodium (salt) excretion by the kidney will, "en passant", cause increased calcium excretion by the kidney)
**after rehydration, a
loop diureticsuch as furosemidecan be given to permit continued large volume intravenous salt and water replacement while minimizing the risk of blood volume overload and pulmonary edema. In addition, loop diureticstend to depress renal calcium reabsorption thereby helping to lower blood calcium levels
**can usually decrease serum calcium by 1-3 mg/dL within 24 h
**caution must be taken to prevent potassium or magnesium depletion
Additional therapy: bisphosphonates and calcitonin
bisphosphonatesare pyrophosphateanalogues with high affinity for bone, especially areas of high bone-turnover.
**they are taken up by
osteoclasts and inhibit osteoclastic bone resorption
**current available drugs include (in order of potency): (1st gen)
etidronate, (2nd gen) tiludronate, IV pamidronate, alendronate, risedronate, and (3rd gen) zoledronate
**all patients with cancer-associated hypercalcemia should receive treatment with
bisphosphonatessince the 'first line' therapy (above) cannot be continued indefinitely nor is it without risk. Further, even if the 'first line' therapy has been effective, it is a virtual certainty that the hypercalcemia will recur in the patient with hypercalcemia of malignancy. Use of bisphoponates in such circumstances, then, becomes both therapeutic and preventative
renal failureand hypercalcemiashould have a risk-benefit analysis before being given bisphosphonates, since they are relatively contraindicated in renal failure.
Calcitoninblocks bone resorption and also increases urinary calcium excretion by inhibiting renal calcium reabsorption
**Usually used in life-threatening hypercalcemia along with rehydration, diuresis, and bisphosphonates
**Helps prevent recurrence of hypercalcemia
**Dose is 4 Units per kg via subcutaneous or intramuscular route every 12 hours, usually not continued indefinitely
*rarely used, or used in special circumstances
plicamycininhibits bone resorption (rarely used)
gallium nitrateinhibits bone resorption and changes structure of bone crystals (rarely used)
glucocorticoidsincrease urinary calcium excretion and decrease intestinal calcium absorption
***no effect in calcium level in normal or 1' hyperparathyroidism
***effective in hypercalcemia due to osteolytic malignancies (
multiple myeloma, leukemia, Hodgkin's lymphoma, carcinoma of the breast) due to antitumor properties
***also effective in
hypervitaminosis Dand sarcoidosis
dialysisusually used in severe hypercalcemia complicated by renal failure. Supplemental phosphate should be monitored and added if necessary
phosphatetherapy can correct the hypophosphatemia in the face of hypercalcemia and lower serum calcium
Disorders of calcium metabolism
ATC code V03#V03AG Drugs for treatment of hypercalcemia
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