Hypercalcemia Treatment & Management

  • Author: Mahendra Agraharkar, MD, MBBS, FACP, FASN; Chief Editor: Vecihi Batuman, MD, FACP, FASN   more...
 
Updated: Mar 18, 2010
 

Medical Care

Treatment depends on the severity of symptoms and the underlying cause.[5]

  • Volume expansion and saline diuresis
    • Volume depletion results from uncontrolled symptoms leading to decreased intake and enhanced renal sodium loss. This tends to exacerbate or perpetuate the hypercalcemia by increasing Na+ reabsorption in the thick ascending limb of the loop of Henle (TALH). Thus, appropriate volume repletion with isotonic sodium chloride solution is an effective short-term treatment for hypercalcemia.
    • Once volume is restored, simultaneous administration of loop diuretics blocks Na+ and calcium reabsorption in the TALH.
    • Replacing ongoing sodium, potassium, chloride, and magnesium losses is important if prolonged sodium chloride and loop diuretic therapy is contemplated.
  • Mobilization
    • Immobilization aggravates hypercalcemia.
    • Whenever possible, weightbearing mobilization should be encouraged.
  • Reduction of gastrointestinal calcium absorption
    • Reduction of dietary calcium and vitamin D intake is effective for treating hypercalcemia due to increased intestinal calcium absorption (eg, in idiopathic infantile hypercalcemia, ie, Williams syndrome).
    • In vitamin D toxicity or extrarenal synthesis of 1,25(OH) D3 (eg, in sarcoidosis), prednisone may help reduce plasma calcium levels by reducing intestinal calcium absorption.
    • Oral phosphate also can be used to form insoluble calcium phosphate in the gut.
  • Inhibition of bone resorption
    • Bisphosphonates inhibit osteoclastic bone resorption and are effective in the treatment of hypercalcemia due to conditions causing increased bone resorption and malignancy-related hypercalcemia.
    • Pamidronate and etidronate can be given intravenously, while risedronate and alendronate may be effective as oral therapy.
    • Calcitonin can be given intramuscularly or subcutaneously, but it becomes less effective after several days of use.
    • Mithramycin blocks osteoclastic function and can be given for severe malignancy-related hypercalcemia. It has significant hepatic, renal, and marrow toxicity.
  • Dialysis: Peritoneal or hemodialysis against calcium-free or lower calcium concentration dialysate solution is highly effective in lowering plasma calcium levels.
Next

Surgical Care

Surgical care is directed toward reversing the underlying cause of hypercalcemia or repairing the orthopedic damage.[6, 7]

  • Prolonged hypercalcemia due to hyperparathyroidism may warrant surgical neck exploration and removal of 1 or more parathyroid glands. This is particularly appropriate if evidence of nephrolithiasis, osteoporosis, reduction of renal function, neuromuscular symptoms, or radiographic bone disease is present.
  • Hypercalcemia due to malignancy, especially if due to a tumor that is producing PTHrP, may require surgical resection of the tumor.
  • Orthopedic complications of prolonged hypercalcemia (eg, osteoporosis), complications of Paget disease, or complications of bony metastases may require orthopedic or neurosurgical intervention.
Previous
Next

Consultations

Consultation with a surgeon or orthopedist may be required, as indicated.

Previous
Proceed to Medication
 
 
Contributor Information and Disclosures
Author

Mahendra Agraharkar, MD, MBBS, FACP, FASN  Clinical Associate Professor of Medicine, Baylor College of Medicine; President and CEO, Space City Associates of Nephrology

Mahendra Agraharkar, MD, MBBS, FACP, FASN is a member of the following medical societies: American College of Physicians, American Society of Nephrology, and National Kidney Foundation

Disclosure: South Shore DaVita Dialysis Center Ownership interest Other

Coauthor(s)

O David Dellinger III, MD  Assistant Professor, Departments of Family Medicine and Internal Medicine, University of Alabama School of Medicine at Birmingham

O David Dellinger III, MD is a member of the following medical societies: American Academy of Hospice and Palliative Medicine, American College of Physicians-American Society of Internal Medicine, American Geriatrics Society, American Medical Directors Association, and American Society of Addiction Medicine

Disclosure: Nothing to disclose.

Arun Kumar Gangakhedkar, FRACP, MD  Consultant, General Pediatrics, Starship Children's Hospital/Waitakere Hospital, Auckland, New Zealand

Disclosure: Nothing to disclose.

Specialty Editor Board

Frank C Brosius III, MD  Nephrology Program Director, Professor of Internal Medicine and Physiology, Department of Internal Medicine, Division of Nephrology, University of Michigan School of Medicine

Frank C Brosius III, MD is a member of the following medical societies: Alpha Omega Alpha, American Diabetes Association, American Society of Nephrology, and Phi Beta Kappa

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD  Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

Christie P Thomas, MBBS, FRCP, FASN, FAHA  Professor, Department of Internal Medicine, Division of Nephrology, Medical Director, Kidney and Kidney/Pancreas Transplant Program, University of Iowa Hospitals and Clinics

Christie P Thomas, MBBS, FRCP, FASN, FAHA is a member of the following medical societies: American College of Physicians, American Federation for Medical Research, American Heart Association, American Society of Nephrology, American Society of Transplantation, American Thoracic Society, International Society of Nephrology, and Royal College of Physicians

Disclosure: Nothing to disclose.

Rebecca J Schmidt, DO, FACP, FASN  Professor of Medicine, Section Chief, Department of Medicine, Section of Nephrology, West Virginia University School of Medicine

Rebecca J Schmidt, DO, FACP, FASN is a member of the following medical societies: American College of Physicians, American Medical Association, American Society of Nephrology, International Society of Nephrology, National Kidney Foundation, Renal Physicians Association, and West Virginia State Medical Association

Disclosure: Renal Ventures Ownership interest Other

Chief Editor

Vecihi Batuman, MD, FACP, FASN  Professor of Medicine, Section of Nephrology-Hypertension, Tulane University School of Medicine; Chief, Medicine Service, Southeast Louisiana Veterans Health Care System

Vecihi Batuman, MD, FACP, FASN is a member of the following medical societies: American College of Physicians, American Society of Hypertension, American Society of Nephrology, and International Society of Nephrology

Disclosure: Nothing to disclose.

References

  1. McKay CP, Portale A. Emerging topics in pediatric bone and mineral disorders 2008. Semin Nephrol. Jul 2009;29(4):370-8. [Medline].

  2. Guarnieri V, Canaff L, Yun FH, et al. Calcium-Sensing Receptor (CASR) Mutations in Hypercalcemic States: Studies from a Single Endocrine Clinic Over Three Years. J Clin Endocrinol Metab. Feb 17 2010;[Medline].

  3. Nissen PH, Christensen SE, Wallace A, et al. Multiplex ligation-dependent probe amplification (MLPA) screening for exon copy number variation in the calcium sensing receptor gene: no large rearrangements identified in patients with calcium metabolic disorders. Clin Endocrinol (Oxf). Nov 11 2009;[Medline].

  4. Alsirafy SA, Sroor MY, Al-Shahri MZ. Hypercalcemia in advanced head and neck squamous cell carcinoma: prevalence and potential impact on palliative care. J Support Oncol. Sep-Oct 2009;7(5):154-7. [Medline].

  5. Makras P, Papapoulos SE. Medical treatment of hypercalcaemia. Hormones (Athens). Apr-Jun 2009;8(2):83-95. [Medline]. [Full Text].

  6. Bergenfelz AO, Jansson SK, Wallin GK, et al. Impact of modern techniques on short-term outcome after surgery for primary hyperparathyroidism: a multicenter study comprising 2,708 patients. Langenbecks Arch Surg. Jul 18 2009;[Medline].

  7. Low TH, Clark J, Gao K, et al. Outcome of parathyroidectomy for patients with renal disease and hyperparathyroidism: predictors for recurrent hyperparathyroidism. ANZ J Surg. May 2009;79(5):378-82. [Medline].

  8. Padhi D, Harris R. Clinical pharmacokinetic and pharmacodynamic profile of cinacalcet hydrochloride. Clin Pharmacokinet. 2009;48(5):303-11. [Medline].

  9. Marcocci C, Chanson P, Shoback D, et al. Cinacalcet reduces serum calcium concentrations in patients with intractable primary hyperparathyroidism. J Clin Endocrinol Metab. Jun 2 2009;[Medline].

  10. al Zahrani A, Levine MA. Primary hyperparathyroidism. Lancet. Apr 26 1997;349(9060):1233-8. [Medline].

  11. Allerheiligen DA, Schoeber J, Houston RE. Hyperparathyroidism. Am Fam Physician. Apr 15 1998;57(8):1795-802, 1807-8. [Medline].

  12. Carroll MF, Schade DS. A practical approach to hypercalcemia. Am Fam Physician. May 1 2003;67(9):1959-66. [Medline].

  13. Falk S, Fallon M. ABC of palliative care. Emergencies. BMJ. Dec 6 1997;315(7121):1525-8. [Medline].

  14. Ganong CA, Kappy MS. Hypercalcemia. In: Berman S, ed. Pediatric Decision Making. 3rd ed. St. Louis, Mo: Mosby-Year Book; 1996:. 128-31.

  15. Hay WW Jr, Hayward AR, Levin MJ, Sondheimer JM, eds. Current Pediatric Diagnosis and Treatment. 14th ed. Stamford, Conn: Appleton & Lange; 1999:. 830-1.

  16. Hoenderop JG, Nilius B, Bindels RJ. Molecular mechanism of active Ca2+ reabsorption in the distal nephron. Annu Rev Physiol. 2002;64:529-49. [Medline].

  17. Inzucchi SE. Management of hypercalcemia. Diagnostic workup, therapeutic options for hyperparathyroidism and other common causes. Postgrad Med. May 2004;115(5):27-36. [Medline].

  18. Lteif AN, Zimmerman D. Bisphosphonates for treatment of childhood hypercalcemia. Pediatrics. Oct 1998;102(4 Pt 1):990-3. [Medline].

  19. Mundy GR, Guise TA. Hypercalcemia of malignancy. Am J Med. Aug 1997;103(2):134-45. [Medline].

  20. Pearce SH. Calcium homeostasis and disorders of the calcium-sensing receptor. J R Coll Physicians Lond. Jan-Feb 1998;32(1):10-4. [Medline].

  21. Postlethwaite RJ. Clinical Pediatric Nephrology. 2nd ed. New York, NY: Butterworth Heinemann; 1994.

  22. Renton P. Radiology of rickets, osteomalacia and hyperparathyroidism. Hosp Med. May 1998;59(5):399-403. [Medline].

  23. Rogers MJ, Watts DJ, Russell RG. Overview of bisphosphonates. Cancer. Oct 15 1997;80(8 Suppl):1652-60. [Medline].

  24. Sharma OP. Vitamin D, calcium, and sarcoidosis. Chest. 1996;109(2):535-539. [Medline].

  25. Strewler GJ. The physiology of parathyroid hormone-related protein. N Engl J Med. Jan 20 2000;342(3):177-85. [Medline].

 
Previous
Next
 
Investigations flowchart.
Vitamin D metabolism.
 
 
 
All material on this website is protected by copyright, Copyright © 1994-2012 by WebMD LLC.
This website also contains material copyrighted by 3rd parties.

DISCLAIMER: The content of this Website is not influenced by sponsors. The site is designed primarily for use by qualified physicians and other medical professionals. The information contained herein should NOT be used as a substitute for the advice of an appropriately qualified and licensed physician or other health care provider. The information provided here is for educational and informational purposes only. In no way should it be considered as offering medical advice. Please check with a physician if you suspect you are ill.