Hypercalcemia

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Hypercalcemia

• Shakir Ejaz

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Etiology what causes it

• Major causes hyperparathyroidism and cancer
• Hyperpara - 1 cause in ambulatory pt
• Malignancy - 1 cause in hospitalized pt
• Also milk alkali is becoming a common cause due
  to use of CaCO3 for osteoporosis

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Other etiologies short word on Rx

• Sarcoidosis other granulomatous dz Rx low
  ca diet, steroids, treat underlying disease
• Familial hypocalciuric hypercalcemia generally
  no Rx as hyperca is mild and aymptomatic.

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Symptoms when to think of it

• CNS confusion, psychosis, lethargy, coma
• GI Constiptaion anorexia, pancreatitis
• Cardiac short QT, prolonged PR and QRS,
  increased QRS voltage, T-wave flattening and
  widening, notching of QRS, AV block, cardiac
  arrest (Cagt15mEq/L)
• Renal volume depletion, renal insufficiency,
  stones, distal RTA

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What labs to order

• Ionized Ca, PO4, Cr, Intact PTH, 1,25-OH vit D,
  25-OH vit D levels

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Treatment - Goals

• Increase urinary calcium excretion
• Inhibit bone resorption
• Decrease intestinal absorption of Ca

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Treatment Increase urinary Ca

• IV fluid resuscitation helps achieve the volume
  defecit from the hyperca.
• Usual starting rate 250-300cc/hr of NS infusion x
  1 day , UO goal 150 cc/hr
• Geared towards clinical response watch for
  hypervolemia.
• Lasix only for hypervolemia.
• Dailysis if CHF, renal insufficiency

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Treatment Inhibit bone resorption

• Calcitonin
• Salmon calcitonin (4 IU / kg) Im or SubQ Q12
  hours x 48 hours (tachyphylaxis)
• Simultaneous steroids may avoid tachyphylaxis

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Treatment inhibit bone resorption (contd)

• Bisphosphonates
• zolendronate (more potent) 4mg IV over 15
  minutes or pamidronate 60-90 mg IV infused over
  4 hrs.
• Onset of action 1-2 days with maximum effect in
  4-6 days.

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In a nutshell

• 70 M , outpt Lung Ca, chronic mild HyperCa (11-12
  mg/dl) still treat as risk of
  nephrocalcinosis/lithiasis. Oral hydration, high
  oral salt, avoid thiazides. Oral phosphates (1-3
  g/day) as long as serum PO4 lt 4mg/dl.
• 60 M in hosp, severe symptoamtic hyperCa
  (gt12mg/dl)
• Saline lasix for hypervol, calcitonin (4
  IU/kg), zolendronic acid (4 mg IV / 15 min)

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Questions on rounds

• Mechanism of hyperCa in malignancy
• diffuse skeletal mets, (2) ectopic prod of
  PTH-rP, (3) elevated vit D metabolites (lymphoma)
  
• Types of hypervit D
• High 25-OH vit D from dietary suppl
• High1,25-OH vit D granulomatous dz, lymphoma,
  meds
• Common meds
• Hctz, lithium, vit A intoxication, antacids
• When to use Steroids? when hyperCa secondary to
  lymphona, granulomatous dz (20-40mg PO pred)