eMedicine Specialties > Nephrology > Acid-Base, Fluid, and Electrolyte Disorders
Hypocalcemia: Treatment & Medication
Updated: Aug 25, 2009
- Overview
- Differential Diagnoses & Workup
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Treatment
Medical Care
The treatment of hypocalcemia depends on the cause, the severity, the presence of symptoms, and how rapidly the hypocalcemia developed.7
- Acute hypocalcemia
- Promptly correct symptomatic or severe hypocalcemia with cardiac arrhythmias or tetany with parenteral administration of calcium salts.
- Administer 1-2 ampules 10% calcium gluconate (93 mg/10 mL) in 50-100 mL of D5W over 5-10 minutes. Calcium chloride 10% solution (273 mg/10-mL ampule) delivers higher amounts of calcium and is advantageous when rapid correction is needed, but it should be administered via central venous access.
- Measure serum calcium every 4-6 hours to maintain serum calcium levels at 8-9 mg/dL. If low albumin is also present, ionized calcium should be monitored.
- Patients with cardiac arrhythmias or patients on digoxin therapy need continuous ECG monitoring during calcium replacement because calcium potentiates digitalis toxicity.
- Identify and treat the cause of hypocalcemia and taper the infusion.
- Start oral calcium and vitamin D treatment early. Patients with postparathyroidectomy hungry bone disease, especially those with osteitis fibrosa cystica, can present with a dramatic picture of hypocalcemia.
- Treatment with calcium and vitamin D for 1-2 days prior to parathyroid surgery may help prevent the development of severe hypocalcemia.
- Promptly correct symptomatic or severe hypocalcemia with cardiac arrhythmias or tetany with parenteral administration of calcium salts.
- Chronic hypocalcemia: Treatment of chronic hypocalcemia depends on the cause of the disorder.
- PTH deficiency: Patients with hypoparathyroidism and pseudohypoparathyroidism can be managed initially with the oral administration of calcium supplements. The hypercalcemic effects of thiazide diuretics may offer some additional benefits. In patients with severe hypoparathyroidism, vitamin D treatment may be required; however, remember that PTH deficiency impairs the conversion of vitamin D to calcitriol. Therefore, the most efficient treatment is the addition of 0.5-2 mcg of calcitriol or 1-alpha-hydroxyvitamin D3.
- Hypocalcemia in patients on dialysis: Most patients on hemodialysis will be hypercalcemic. However, postparathyroidectomy, patients may have considerable difficulty in maintaining appropriate calcium levels. These levels can be managed several ways. First, oral calcium supplements should be provided. They must be given between meals; otherwise, they will primarily act as phosphate binders. Active vitamin D administration (calcitriol) enhances the absorption of calcium. Finally, the calcium in the dialysate bath can be increased.
- Nutritional vitamin D deficiency from lack of sunlight exposure or poor oral intake of vitamin D: Ultraviolet light or sunlight exposure can treat these patients.33 Treat nutritional rickets with vitamin D2. Oral calcium preparations containing 1-2 g of elemental calcium per day can treat patients with a calcium deficiency. For infants who are breastfed, adjust the dose to 30 mg/kg/d. Calcitriol may be used, but it has the disadvantages of a higher price and the possibility of producing hypervitaminosis D with hypercalcemia.
Surgical Care
Parathyroidectomy (subtotal or total) may be indicated in certain patients with severe secondary hyperparathyroidism and renal osteodystrophy.
Diet
- An increase in dietary calcium to greater than 1 g/d is an important part of the treatment of chronic hypocalcemia, particularly in cases of vitamin D deficiency.
- In patients with hypocalcemia and chronic renal failure, the dietary intake of phosphate should be lowered to 400-800 mg/d to prevent hyperphosphatemia.
Medication
The goals of pharmacotherapy are to reduce morbidity and to prevent complications.
Electrolytes
Restores serum calcium levels. Calcium chloride delivers 3 times more elemental calcium than calcium gluconate.
Calcium chloride
Ventricular fibrillation not associated with hyperkalemia, digitalis toxicity, hypercalcemia, renal insufficiency, or cardiac disease. Preferred when patient is in cardiac arrest and in other serious cases. Ten mL of calcium chloride 10% (1 g/10 mL) contain 272 mg of elemental calcium.
Adult
2-4 mg/kg IV over 10 min; repeat prn, followed by continuous infusion of 0.5-2 mg/kg/h to restore levels to 8-9 mg/dL
Pediatric
0.2 mL (20 mg)/kg IV
Coadministration with digoxin may cause arrhythmias; with thiazides, may induce hypercalcemia; may antagonize effects of calcium channel blockers, especially verapamil; decreases effects of atenolol, tetracyclines, salicylates, fluoroquinolones, and sodium polystyrene sulfonate
Documented hypersensitivity; ventricular fibrillation not associated with hyperkalemia; digitalis toxicity; hypercalcemia; renal insufficiency; cardiac disease
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Administer slowly (not to exceed 0.5-1 mL/min); probably only should be administered via central venous access to prevent phlebitis and avoid potential soft tissue damage; hypercalcemia may occur in renal failure; hypophosphatemia; hyperphosphatemia; monitor ECG during calcium infusion because calcium potentiates digitalis toxicity; respiratory failure; acidosis
Calcium gluconate (Kalcinate)
Moderates nerve and muscle performance, and facilitates normal cardiac function. Can be administered IV initially; then, maintain calcium levels with high calcium diet. Some patients require oral calcium supplementation. One ampule contains 93 mg of elemental calcium.
Adult
100-300 mg elemental calcium IV diluted in 100 mL D5W over 10 min; initial rate of infusion should be 0.3-2 mg of elemental calcium per kg/h
Pediatric
2 mg/kg of elemental calcium IV (about 20 mg/kg of calcium gluconate 10%)
May decrease effects of tetracyclines, atenolol, salicylates, iron salts, and fluoroquinolones; antagonizes effects of verapamil; large intakes of dietary fiber may decrease calcium absorption and levels
Documented hypersensitivity; renal calculi; hypercalcemia; hypophosphatemia; renal or cardiac disease; digitalis toxicity
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Caution in digitalized patients, respiratory failure, acidosis, and severe hyperphosphatemia
Calcium carbonate (Oystercal, Caltrate)
Indicated to restore and maintain normocalcemia when hypocalcemia is not severe enough to warrant rapid replacement.
Adult
0.5-1 g PO bid/tid
Pediatric
45-65 mg/kg/d PO divided qid
May decrease effects of tetracyclines, atenolol, salicylates, iron salts, and fluoroquinolones; large intakes of dietary fiber may decrease calcium absorption and levels; calcium potentiates digitalis effects
Documented hypersensitivity; renal calculi; hypercalcemia; hypophosphatemia; renal or cardiac disease; digitalis toxicity
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Caution in digitalized patients, respiratory failure, and acidosis
Vitamins
Restore calcium levels in conditions associated with vitamin D deficiency. Vitamin D helps control hyperparathyroidism in patients with chronic renal failure and end-stage renal disease.
Calcitriol (Calcijex, Rocaltrol)
Increases calcium levels by promoting calcium absorption in intestines and calcium retention in kidneys. To prevent hyperparathyroidism, patients on dialysis may require higher doses, >1 mcg/d divided 2-3 times per wk.
Adult
Calcitriol: 0.25-1 mcg/d PO
D2: 1500-5000 IU/d PO; 10,000-50,000 IU/mo IM
Pediatric
Initial: 15 ng/kg/d PO
Maintenance: 5-40 ng/kg/d PO
Cholestyramine and colestipol decrease absorption of calcitriol; magnesium-containing antacids and thiazide diuretics can increase calcitriol effects
Documented hypersensitivity; hypercalcemia; malabsorption syndrome; hyperphosphatemia
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Adequate response to calcitriol depends on adequate dietary calcium intake; maintain adequate fluid intake; may cause hypervitaminosis D with hypercalcemia
More on Hypocalcemia |
| Overview: Hypocalcemia |
| Differential Diagnoses & Workup: Hypocalcemia |
 Treatment & Medication: Hypocalcemia |
| Follow-up: Hypocalcemia |
| Multimedia: Hypocalcemia |
| References |
| Further Reading |
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Further Reading
Clinical trials:
Evaluation of Parathyroid Hormone Pump Therapy
Impact on Reducing the Incidence of Low Serum Calcium by Providing Educational Materials on the Need to Take Daily Supplemental Calcium and Vitamin D to Patients With Paget's Disease Treated With Reclast®
Resistance to Vitamin D or Parathyroid Hormone
Studies of Elevated Parathyroid Activity
Keywords
hypocalcemia, low calcium, serum calcium, hypercalcemia, vitamin D deficiency, magnesium deficiency, hypocalcemia causes, hypocalcemia symptoms, hypocalcemia treatment, serum calcium levels, calcium-sensing receptor, ionized calcium concentration, chronic renal failure, acute renal failure, acute pancreatitis, hypoparathyroidism, pseudohypoparathyroidism
