Hypercalcemia

Hypercalcemia: (N: 8.4-10.2)

  • Drug-induced hypercalcemia: (10.2 – 10.5)
    • HCTZ: causes high normal or modestly elevated calcium level
      • Slightly increases calcium by increasing the renal tubular calcium absorption.
    • Lithium
  • Primary hyperparathyroidism:***most common cause of hypercalcemia*** [parathyroid adenoma] (ex: 12.0)
    • Usually asymptomatic and present with incidental hypercalcemia on routine labs
    • Serum calcium is only mildly elevated: Ex: 12.0
  • Hypercalcemia of malignancy: (2nd most common cause) Significantly elevated calcium: >+13-14
    • Rapid onset with moderate to high serum calcium levels,
    • Associated with symptoms of hypercalcemia or symptoms of the primary malignancy.
      1. Symptoms of hypercalcemia: “Stones, Bones, Groans, Thrones, and Psychiatric Overtones”
        • Stones (renal or biliary)
        • Bones (bone pain)
        • Groans (abdominal pain, nausea and vomiting)
        • Thrones (polyuria) resulting in dehydration
        • Psychiatric overtones (Depression 30–40%, anxiety, cognitive dysfunction, insomnia, coma)
    • Initial management: Give Lasix repeatedly as BP can tolerate with IV fluids
      • Fluid replacement with normal saline to correct the volume depletion that is invariably present and to enhance renal calcium excretion,
    • Although intravenous Pamidronate (Pamidronate disodium (Aredia) by intravenous infusion) has become the mainstay of treatment for the hypercalcemia of malignancy, it is considered only after the hypercalcemic patient has been rendered euvolemic by saline repletion. The same is true for the other calcium-lowering agent (ex: Calcitonin-salmon (Miacalcin) subcutaneously).
      • PAMIDRONATE INJ 60 MG in NORMAL SALINE INJ 500 ml IVPB INFUSE OVER 240 MINUTES ONCE. Infuse over 4 hours after patient completes 1 liter of NS.
      • Give 1 dose of 60mg Pamidronate to further decrease serum calcium, and place Lasix on hold in order to maintain adequate hydration status while on Pamidronate.
    • Ex: Multiple Myeloma: C-A-R
      • Hypercalcemia (ex: 14-15). Lytic bone lesions.
      • Anemia
      • Renal failure (CKD)

Granulomatous disease (ex: Sarcoid, fungal infection, TB)

  1. Cause hypercalcemia by extra-renal production of 1-alpha hydroxylase, which increases the formation of 1,25(OH)2 vitamin D.
  2. These patients have symptoms of their primary disease. (not asymptomatic!)
Source: http://www.uptodate.com/contents/image?imageKey=ENDO%2F104081&topicKey=ENDO%2F2029&rank=1%7E103&source=see_link&search=primary+hyperparathyroidism&utdPopup=true

Source: http://www.uptodate.com/contents/image?imageKey=ENDO%2F104081&topicKey=ENDO%2F2029&rank=1%7E103&source=see_link&search=primary+hyperparathyroidism&utdPopup=true

 

 

 

Source: http://www.uptodate.com/contents/image?imageKey=ENDO%2F104081&topicKey=ENDO%2F2029&rank=1%7E103&source=see_link&search=primary+hyperparathyroidism&utdPopup=true

Source: http://www.uptodate.com/contents/image?imageKey=ENDO%2F104081&topicKey=ENDO%2F2029&rank=1%7E103&source=see_link&search=primary+hyperparathyroidism&utdPopup=true

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