Milk-Alkali Syndrome Treatment & Management
- Author: R Hal Scofield, MD; Chief Editor: George T Griffing, MD more...
The only care required is discontinuation of calcium carbonate or reduction of the dose to no more than 1200-1500mg of elemental calcium daily. In most patients, calcium supplementation should be changed to a form of calcium other than calcium carbonate. Thus, absorbable alkali is avoided.
The patient should be admitted to the hospital. Saline diuresis, produced by infusion of large volumes of intravenous isotonic sodium chloride solution, is the treatment of choice. Further calciuresis can be induced by treatment with intravenous loop diuretics, although the utility of loop diuretics for hypercalcemia has been questioned.
The typical patient is volume depleted; therefore, volume should be replaced with saline prior to institution of diuretic therapy. Care should be taken to not induce volume depletion with the diuretics, because this may worsen the hypercalcemia.
Calcium carbonate should be stopped to resolve the pathophysiology that produced the hypercalcemia. As stated previously, however, patients with milk-alkali syndrome may become transiently hypocalcemic during treatment with intravenous saline and intravenous diuretics.
Because laboratory studies such as PTH measurements will not have returned to normal when therapy is instituted, the serum calcium level must be monitored closely.
Pamidronate has been used successfully in the treatment of hypercalcemia secondary to milk-alkali syndrome. However, treatment of milk-alkali syndrome with bisphosphonates was associated with hypocalcemia in one series; 6 of 11 patients with milk-alkali syndrome developed treatment-induced hypocalcemia, with 5 of the 6 patients having received bisphosphonates, while in the author’s series of 6 patients, none of whom received bisphosphonate, only 1 developed hypocalcemia.
If hypocalcemia develops in the course of treatment, this usually can be treated with oral calcium supplementation. A calcium source without absorbable alkali, such as calcium citrate, is preferred. Rarely, intravenous calcium might be required to treat severe hypocalcemia.
Diet and activity
A low-calcium, low-phosphorus diet is required during hypercalcemia. No activity restrictions are necessary.
Consultation with a nephrologist may be needed with severe renal disease and/or severe hypercalcemia, because dialysis sometimes is required. Consultation with an endocrinologist may be needed for interpretation of PTH and other laboratory studies.
Occasionally, dialysis may be required with severe renal impairment. With elevated serum calcium and phosphorus levels, dialysis may be needed to urgently lower these parameters. This may prevent ectopic calcification.
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|Mean Age||51 Years (Range, 24-95 y)|
|Sex||35 men and 43 women|
|Calcium source||Calcium carbonate in all but 1|
|Ingestion of bicarbonate||In 7 patients|
|Ingestion of milk||In 20 patients (plus one who ate yogurt)|
|Mean serum calcium||15.1mg/dL (3.75mmol/L) (range, 11.1-27.5mg/dL)|
|High serum phosphorus||In 12 patients|
|Permanent renal insufficiency||In 20 of 57 patients eligible for evaluation|
|Parathyroid exploration||In 3 patients|
|Hypocalcemia with treatment||In 16 patients|
|*These data are derived from the 7 patients reported, plus the 28 reviewed in Beall and Scofield, 1995, as well as additional patients reported by Gibbs and Lee, 1992; Nakanishi et al, 1992 ; Brandwein and Sigman, 1994 ; Campbell et al, 1994 ; Duthie et al, 1995 ; Spital and Freedman, 1995 ; Fiorino, 1996 ; Lin et al, 1996 ; Muldowney and Mazbar, 1996 ; Sulkin and Krentz, 1999 ;
Camidge and Peaston, 2000 ; George and Clark, 2000 ; Vanpee et al, 2000 ; Liu et al, 2002 ; Robertson, 2002 ; Morton, 2002 ; Kleinig and Torpy, 2004 ; Picolos et al, 2005 ; Gordon et al, 2005 ; Addington et al, 2006 ; Verburg et al, 2006 ; Ennen and Magann, 2006 ; Caruso et al, 2007 ; Dinnerstein et al, 2007 ; Javid et al, 2007; Kaklamanos and Perros, 2007 ; Shah et al, 2007 ; Irtiza-Ali et al, 2008 ; and Jousten and Guffens, 2008.
Two of the patients were pregnant.