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Hypercalcemia

Hypercalcemia Elevation of calcium level in the blood.

Immediate Questions:

A.Vital signs? B.Mental status?B. Underlying condition(s)?

Potential etiologies

1. Malignancy: bone mets, ectopic PTH, osteoclast activating factor 2. Primary hyperparathyroidism 3. Myeloma 4. Vitamin D excess

Potential etiologies 5. Sarcoid / granulomatous disease 6. Milk alkali 7. Other: hyperthyroidism, thiazide diuretics, lithium, immobilization (especially children)

Differential Diagnosis

Among outpatients, malignancy and primary hyperparathyroidism are leading diagnoses. Malignancy predominates as an etiology for hypercalcemia among hospitalized individuals.

TherapyPatients usually are profoundly volume depleted and can require several liters of NS volume replacement. Volume replacement is the initial step in management. Lasix can be added to help increase a saline diuresis (>2500 ml urine/day) and calcium excretion but should only be used following volume replacement._______________________________________

Agent Dose Comments

Saline + furosemide 40-80 mg IV each 2 hours monitor hourly urine output, (diuretic only if plus NS equal to urine monitor electrolytes frequently adequately hydrated) output

Mithramycin 25 mcg/kg IV every response takes 24 hours; can 2-3 days cause bone marrow suppression

Agent Dose Comments

Pamidronate 60-80 mg IV over 6 to response in 3 to 4 days, which (mainstay of therapy) 24 hours lasts up to 7 to 14 days

Prednisone 40-60 mg per day antagonize actions vitamin D; decreases calcium absorption and increases calcium excretion; in most cases, effect lasts only for a few days