Hypercalcaemia (Secondary Care)

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Serum calcium levels are tightly regulated through regulatory mechanisms. Abnormalities of parathyroid function, renal calcium absorption, bone resorption, dihydroxylation of vitamin D and malignancy can result in hypo/hypercalcaemia. Calcium is bound to albumin and corrected calcium (adjusting for albumin) can be calculated using the formula: 
corrected calcium = serum calcium + 0.022 x (40 - serum albumin)
This is automatically calculated on the biochemistry report and normal serum corrected calcium levels sit between 2.2 to 2.6.
90% of hypercalcaemia is due to hyperparathyroidism or malignancy.

For the management of hypercalcaemia in Palliative Care see: Scottish Palliative Care Guidelines.

Presentation

Symptoms: Think STONES, BONES, ABDOMINAL GROANS, THRONES, PSYCHIATRIC OVERTONES

Signs/Symptoms
  • Gastrointestinal: Anorexia, Nausea, Constipation, Peptic Ulceration, Pancreatitis
  • Cardiac: Shortened QT, Dysrhythmias, Hypertension, Cardiomyopathy
  • Renal: Polyuria, Polydipsia, Nephrolithiasis, Nephrocalcinosis, Renal Impairment
  • Neuropsychiatric: Muscle Weakness, Mood Disturbance, Confusion, Coma
History

Important to ask about the duration of symptoms and symptoms suggestive of malignancy: weight loss, cough, bowel disturbance, sweats, family history, medications (including over the counter and supplements)

Initial management

  • Fluid status: urine output, HR, BP, skin temperature, CRT, thirst
  • GCS
  • Neck/respiratory/abdominal/breast/groin exam: Looking for evidence of malignancy
  • Bloods: calcium, phosphate, magnesium, PTH, U&Es, TSH, vitamin D
  • ECG +/- Cardiac monitoring
  • Stop any potentially causative medications (particularly calcium supplements and thiazide diuretics)
  • Corrected calcium, as in the table below:
Corrected calcium
<3.0 If asymptomatic does not require urgent correction
3 to 3.5 May be tolerated if slow rise – if symptomatic prompt treatment usually indicated
>3.5 Urgent treatment; high risk of arrhythmia and coma

Treatment

4 to 6L 0.9% NaCl, IV over 24 Hours

  • Tailor as appropriate for patient – reduce fluid volume in elderly, renal impairment and heart failure.
  • Loop diuretics only indicated if overloaded and will not lower calcium.
  • If severe renal impairment consider discussing with renal team re: Dialysis

After fluid resuscitation: IV bisphosphonate (NB this is an off-label indication, it is only licensed in hypercalcaemia related to malignancy)

  • Care if AKI/CKD
  • Zoledronic Acid, 4mg over 15 minutes
  • OR pamidronate, 30mg to 90mg (depending on severity) at 20mg/hour (routinely given in divided doses)
  • Calcium reaches lowest at 2 to 4 days, can stay low if vitamin D deficient (common in Scotland) or if PTH is suppressed.

Escalation

  • If calcium >3.5, shortened QTC, arrhythmia, coma – escalate urgently to senior
  • Discuss with renal team early if severe AKI as may need dialysis

Further information for Health Care Professionals

Glossary

Abbreviation  Meaning 
AKI  acute kidney injury 
BP  blood pressure 
CRT  cardiac resynchronisation therapy
ECG  electrocardiogram
HR  heart rate 
IV  Intravenous 
NaCI  Sodium chloride
PTH  parathyroid gland 
QTc QT corrected for heart rate
U&E  urine and electrolytes 
TSH  thyroid stimulating hormone 

Last reviewed: 31 August 2022

Next review: 31 August 2025

Version: 1

Approved By: Approved TAMSG of the ADTC

Reviewer Name(s): Euan Park, ACC EM Trainee, Alison Heggie, Endocrinology/Acute Medicine Consultant Wiliam Rutherford, Acute Medicine/Stroke/MHDU Consultant

Document Id: TAM527

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