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Hypocalcemia Treatment & Management

  • Author: Manish Suneja, MD; Chief Editor: Vecihi Batuman, MD, FACP, FASN  more...
 
Updated: Jul 26, 2016
 

Approach Considerations

The treatment of hypocalcemia depends on the cause, the severity, the presence of symptoms, and how rapidly the hypocalcemia developed.[34] Hypocalcemia generally results from another disease process. Awareness of the diseases that cause hypocalcemia is important so that the cause can be identified and managed early.

Most hypocalcemic emergencies are mild and require only supportive treatment and further laboratory evaluation. On occasion, severe hypocalcemia may result in seizures, tetany, refractory hypotension, or arrhythmias that require a more aggressive approach.

In the emergency department, magnesium and calcium (in their many different forms) are the only medications necessary to treat hypocalcemic emergencies. The consulting endocrinologist may choose to prescribe any of the various vitamin D supplements depending on laboratory workup findings, and oral calcium supplementation for outpatient therapy.

Hypocalcemia is found in over half the patients admitted to intensive care units (ICUs).[42, 30] Studies in critically ill patients have yielded conflicting results, with some suggesting that hypocalcemia is likely a marker of disease severity, and that calcium values usually normalize spontaneously with resolution of the primary disease process.[43, 30] Indeed it has been posited that low levels in critical illness may be protective and attempted correction may be harmful.[43]

In contrast, other studies have concluded that both moderate and mild hypocalcemia are associated with increased mortality, whereas mild hypercalcemia is associated with lower mortality.[42]   One large retrospective study found that calcium supplementation during the ICU stay improved 28-day survival in critically ill adult patients.[44]

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Mild Hypocalcemia

In patients whose symptoms are not life-threatening, confirm ionized hypocalcemia and check other pertinent laboratory tests. If the cause is not obvious, send a blood sample for a PTH level. Depending on the PTH level, the endocrinologist may do further laboratory workup, particularly an evaluation of vitamin D levels.

Oral repletion may be indicated for outpatient treatment; patients requiring intravenous (IV) repletion should be admitted. The recommended dose of elemental calcium in healthy adults is 1-3 g/d.)

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Severe Hypocalcemia

Supportive treatment (ie, IV fluid replacement, oxygen, monitoring) often is required prior to directed treatment of hypocalcemia. Be aware that severe hypocalcemia often is associated with other life-threatening conditions. Check ionized calcium and other pertinent screening laboratory tests.

IV replacement is recommended in symptomatic or severe hypocalcemia with cardiac arrhythmias or tetany. Doses of 100-300 mg of elemental calcium (10 mL of calcium gluconate contains 90 mg elemental calcium; 10 mL of calcium chloride contains 272 mg elemental calcium) in 50-100 mL of 5% dextrose in water (D5W) should be given over 5-10 minutes. This dosage raises the ionized level to 0.5-1.5 mmol and should last 1-2 hours. Caution should be used when giving calcium chloride intravenously.

Calcium chloride 10% solution delivers higher amounts of calcium and is advantageous when rapid correction is needed, but it should be administered via central venous access. Calcium infusion drips should be started at 0.5 mg/kg/hr and increased to 2 mg/kg/hr as needed, with an arterial line placed for frequent measurement of ionized calcium.

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. Admit the patient for further evaluation and observation.

Patients with cardiac arrhythmias or patients on digoxin therapy need continuous electrocardiographic (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.

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Chronic Hypocalcemia

Treatment of chronic hypocalcemia depends on the cause of the disorder. Patients with hypoparathyroidism and pseudohypoparathyroidism can be managed initially with oral 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. Parathyroidectomy (subtotal or total) may be indicated in certain patients with severe secondary hyperparathyroidism and renal osteodystrophy.

Recombinant human parathyroid hormone (rhPTH, Natpara) is commercially available in the United States and is indicated as an adjunct to calcium and vitamin D to control hypocalcemia in patients with hypoparathyroidism. Its approval was based on the REPLACE trial, in which 48 of 90 patients (53%) receiving rhPTH, but only one of 44 patients in the placebo group (2%), achieved >50% reduction of daily PO calcium and vitamin D from baseline while maintaining serum calcium above baseline concentrations and less than upper limits of normal at week 24 (P < 0.0001).[45]

Although most patients on hemodialysis will be hypercalcemic, those who have undergone parathyroidectomy 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 (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 responds to treatment with ultraviolet light or sunlight exposure.[46] 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/day. Calcitriol may be used, but it has the disadvantages of a higher price and the possibility of producing hypervitaminosis D with hypercalcemia.

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Diet

An increase in dietary calcium to greater than 1 g/day 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/day to prevent hyperphosphatemia.

Patients with chronic hypocalcemia should be educated about the early symptoms of hypocalcemia, such as paresthesias and muscle weakness, so that they can obtain care before more severe symptoms develop.

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Consultations and Long-Term Monitoring

Given the variety of causes that hypocalcemia may have, multiple consultations may be necessary. Depending on the clinical situation, consultations may include one or more of the following:

  • Internist
  • Endocrinologist
  • Intensivist
  • Surgeon
  • Oncologist
  • Nephrologist
  • Dietitian
  • Toxicologist [47]

After determining the cause of hypocalcemia, direct the treatment at preventing further episodes of hypocalcemia and avoiding the complications of chronic hypocalcemia. Although uncommon, outpatient evaluation by an endocrinologist or an internist is appropriate in some patients who present to the ED with hypocalcemia. Patients with diseases that predispose them to the development of hypocalcemia should have scheduled appointments with an outpatient provider.

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Contributor Information and Disclosures
Author

Manish Suneja, MD Associate Professor, Department of Internal Medicine, Division of Nephrology, University of Iowa Hospitals and Clinics

Manish Suneja, MD is a member of the following medical societies: American College of Physicians, American Society of Nephrology, National Kidney Foundation

Disclosure: Nothing to disclose.

Coauthor(s)

Heather A Muster, MD, MS Medical Director, Davita Clinical Research

Heather A Muster, MD, MS is a member of the following medical societies: American College of Physicians, American Society of Nephrology, American Society of Transplantation, International Society of Nephrology, Minnesota Medical Association, National Kidney Foundation

Disclosure: Nothing to disclose.

Specialty Editor Board

Eleanor Lederer, MD, FASN Professor of Medicine, Chief, Nephrology Division, Director, Nephrology Training Program, Director, Metabolic Stone Clinic, Kidney Disease Program, University of Louisville School of Medicine; Consulting Staff, Louisville Veterans Affairs Hospital

Eleanor Lederer, MD, FASN is a member of the following medical societies: American Association for the Advancement of Science, International Society of Nephrology, American Society for Biochemistry and Molecular Biology, American Federation for Medical Research, American Society for Bone and Mineral Research, American Society of Nephrology, American Society of Transplantation, Kentucky Medical Association, National Kidney Foundation, Phi Beta Kappa

Disclosure: Received grant/research funds from Dept of Veterans Affairs for research; Received salary from American Society of Nephrology for asn council position; Received salary from University of Louisville for employment; Received salary from University of Louisville Physicians for employment; Received contract payment from American Physician Institute for Advanced Professional Studies, LLC for independent contractor; Received contract payment from Healthcare Quality Strategies, Inc for independent cont.

Chief Editor

Vecihi Batuman, MD, FACP, FASN Huberwald Professor of Medicine, Section of Nephrology-Hypertension, Tulane University School of Medicine; Chief, Renal Section, 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, International Society of Nephrology

Disclosure: Nothing to disclose.

Acknowledgements

Jeffrey L Arnold, MD, FACEP Chairman, Department of Emergency Medicine, Santa Clara Valley Medical Center

Jeffrey L Arnold, MD, FACEP is a member of the following medical societies: American Academy of Emergency Medicine and American College of Physicians

Disclosure: Nothing to disclose.

Christopher B Beach, MD, FACEP, FAAEM Associate Professor and Vice Chair of Emergency Medicine, Department of Emergency Medicine, Associate Professor of Institute for Healthcare Studies, Institute for Patient Safety, Feinberg School of Medicine, Northwestern University

Christopher B Beach, MD, FACEP, FAAEM is a member of the following medical societies: Alpha Omega Alpha, American Academy of Emergency Medicine, American College of Emergency Physicians, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Robin R Hemphill, MD, MPH Associate Professor, Director, Quality and Safety, Department of Emergency Medicine, Emory University

Robin R Hemphill, MD, MPH is a member of the following medical societies: American College of Emergency Physicians and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Eleanor Lederer, MD Professor of Medicine, Chief, Nephrology Division, Director, Nephrology Training Program, Director, Metabolic Stone Clinic, Kidney Disease Program, University of Louisville School of Medicine; Consulting Staff, Louisville Veterans Affairs Hospital

Eleanor Lederer, MD is a member of the following medical societies: American Association for the Advancement of Science, American Federation for Medical Research, American Society for Biochemistry and Molecular Biology, American Society for Bone and Mineral Research, American Society of Nephrology, American Society of Transplantation, International Society of Nephrology, Kentucky Medical Association, National Kidney Foundation, and Phi Beta Kappa

Disclosure: Dept of Veterans Affairs Grant/research funds Research

James W Lohr, MD Professor, Department of Internal Medicine, Division of Nephrology, Fellowship Program Director, University of Buffalo State University of New York School of Medicine and Biomedical Sciences

James W Lohr, MD is a member of the following medical societies: American College of Physicians, American Heart Association, American Society of Nephrology, and Central Society for Clinical Research

Disclosure: Genzyme Honoraria Speaking and teaching

Alfredo A Pegoraro, MD Consulting Staff, Nephrology Associates

Alfredo A Pegoraro, MD is a member of the following medical societies: American Medical Assocation, American Society of Nephrology, and International Society of Nephrology

Disclosure: Nothing to disclose.

Erik D Schraga, MD Staff Physician, Department of Emergency Medicine, Mills-Peninsula Emergency Medical Associates

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

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Electrocardiogram (ECG) findings in severe hypocalcemia.
 
 
 
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