Hypocalcemia Treatment & Management
- Author: Manish Suneja, MD; Chief Editor: Vecihi Batuman, MD, FACP, FASN more...
Approach Considerations
The treatment of hypocalcemia depends on the cause, the severity, the presence of symptoms, and how rapidly the hypocalcemia developed.[30] 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.
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.)
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.
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.
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.[38] 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.
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.
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[39]
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.
Levine BA, Williams RP. Calcium binding to proteins and other large biological anion centers. Academic Press. 1982;II:1.
Pedersen KO. Binding of calcium to serum albumin. I. Stoichiometry and intrinsic association constant at physiological pH, ionic strength, and temperature. Scand J Clin Lab Invest. Dec 1971;28(4):459-69. [Medline].
Sarko J. Bone and mineral metabolism. Emerg Med Clin North Am. Aug 2005;23(3):703-21, viii. [Medline].
Hofer AM, Brown EM. Extracellular calcium sensing and signalling. Nat Rev Mol Cell Biol. Jul 2003;4(7):530-8. [Medline].
Mundy GR, Guise TA. Hormonal control of calcium homeostasis. Clin Chem. Aug 1999;45(8 Pt 2):1347-52. [Medline].
Silver J, Yalcindag C, Sela-Brown A, Kilav R, Naveh-Many T. Regulation of the parathyroid hormone gene by vitamin D, calcium and phosphate. Kidney Int Suppl. Dec 1999;73:S2-7. [Medline].
Yamamoto M, Kawanobe Y, Takahashi H, Shimazawa E, Kimura S, Ogata E. Vitamin D deficiency and renal calcium transport in the rat. J Clin Invest. Aug 1984;74(2):507-13. [Medline].
Shoback D. Clinical practice. Hypoparathyroidism. N Engl J Med. Jul 24 2008;359(4):391-403. [Medline].
Burch WM, Posillico JT. Hypoparathyroidism after I-131 therapy with subsequent return of parathyroid function. J Clin Endocrinol Metab. Aug 1983;57(2):398-401. [Medline].
Cruz DN, Perazella MA. Biochemical aberrations in a dialysis patient following parathyroidectomy. Am J Kidney Dis. May 1997;29(5):759-62. [Medline].
Looker AC, Dawson-Hughes B, Calvo MS, Gunter EW, Sahyoun NR. Serum 25-hydroxyvitamin D status of adolescents and adults in two seasonal subpopulations from NHANES III. Bone. May 2002;30(5):771-7. [Medline].
Linnebur SA, Vondracek SF, Vande Griend JP, Ruscin JM, McDermott MT. Prevalence of vitamin D insufficiency in elderly ambulatory outpatients in Denver, Colorado. Am J Geriatr Pharmacother. Mar 2007;5(1):1-8. [Medline].
Barone A, Giusti A, Pioli G, Girasole G, Razzano M, Pizzonia M, et al. Secondary hyperparathyroidism due to hypovitaminosis D affects bone mineral density response to alendronate in elderly women with osteoporosis: a randomized controlled trial. J Am Geriatr Soc. May 2007;55(5):752-7. [Medline].
Beckerman P, Silver J. Vitamin D and the parathyroid. Am J Med Sci. Jun 1999;317(6):363-9. [Medline].
Johnson JM, Maher JW, DeMaria EJ, Downs RW, Wolfe LG, Kellum JM. The long-term effects of gastric bypass on vitamin D metabolism. Ann Surg. May 2006;243(5):701-4; discussion 704-5. [Medline].
Brasier AR, Nussbaum SR. Hungry bone syndrome: clinical and biochemical predictors of its occurrence after parathyroid surgery. Am J Med. Apr 1988;84(4):654-60. [Medline].
Dettelbach MA, Deftos LJ, Stewart AF. Intraperitoneal free fatty acids induce severe hypocalcemia in rats: a model for the hypocalcemia of pancreatitis. J Bone Miner Res. Dec 1990;5(12):1249-55. [Medline].
Szczech LA. The impact of calcimimetic agents on the use of different classes of phosphate binders: results of recent clinical trials. Kidney International. 2004;90:S46-48.
Kido Y, Okamura T, Tomikawa M, Yamamoto M, Shiraishi M, Okada Y. Hypocalcemia associated with 5-fluorouracil and low dose leucovorin in patients with advanced colorectal or gastric carcinomas. Cancer. Oct 15 1996;78(8):1794-7. [Medline].
Recker RR, Lewiecki EM, Miller PD, Reiffel J. Safety of bisphosphonates in the treatment of osteoporosis. Am J Med. Feb 2009;122(2 Suppl):S22-32. [Medline].
Stamp TC, Round JM, Rowe DJ, Haddad JG. Plasma levels and therapeutic effect of 25-hydroxycholecalciferol in epileptic patients taking anticonvulsant drugs. Br Med J. Oct 7 1972;4(5831):9-12. [Medline].
Dykes C, Cash BD. Key safety issues of bowel preparations for colonoscopy and importance of adequate hydration. Gastroenterol Nurs. Jan-Feb 2008;31(1):30-5; quiz 36-7. [Medline].
Niemeijer ND, Rijk MC, van Guldener C. Symptomatic hypocalcemia after sodium phosphate preparation in an adult with asymptomatic hypoparathyroidism. Eur J Gastroenterol Hepatol. Apr 2008;20(4):356-8. [Medline].
Lier H, Krep H, Schroeder S, Stuber F. Preconditions of hemostasis in trauma: a review. The influence of acidosis, hypocalcemia, anemia, and hypothermia on functional hemostasis in trauma. J Trauma. Oct 2008;65(4):951-60. [Medline].
Desai TK, Carlson RW, Geheb MA. Prevalence and clinical implications of hypocalcemia in acutely ill patients in a medical intensive care setting. Am J Med. Feb 1988;84(2):209-14. [Medline].
Zivin JR, Gooley T, Zager RA, Ryan MJ. Hypocalcemia: a pervasive metabolic abnormality in the critically ill. Am J Kidney Dis. Apr 2001;37(4):689-98. [Medline].
Forsythe RM, Wessel CB, Billiar TR, Angus DC, Rosengart MR. Parenteral calcium for intensive care unit patients. Cochrane Database Syst Rev. 2008;(4):CD006163. [Medline].
Russell CF, Edis AJ. Surgery for primary hyperparathyroidism: experience with 500 consecutive cases and evaluation of the role of surgery in the asymptomatic patient. Br J Surg. May 1982;69(5):244-7. [Medline].
Hurley K, Baggs D. Hypocalcemic cardiac failure in the emergency department. J Emerg Med. Feb 2005;28(2):155-9. [Medline].
Cooper MS, Gittoes NJ. Diagnosis and management of hypocalcaemia. BMJ. Jun 7 2008;336(7656):1298-302. [Medline].
Kaye M, Somerville PJ, Lowe G, Ketis M, Schneider W. Hypocalcemic tetany and metabolic alkalosis in a dialysis patient: an unusual event. Am J Kidney Dis. Sep 1997;30(3):440-4. [Medline].
Eraut D. Idiopathic hypoparathyroidism presenting as dementia. Br Med J. Mar 9 1974;1(5905):429-30. [Medline].
Murphy G, Bartle S. Hypocalcemic laryngospasm and tetany in a child with renal dysplasia. Pediatr Emerg Care. Jul 2006;22(7):507-9. [Medline].
Soffer D, Licht A, Yaar I, Abramsky O. Paroxysmal choreoathetosis as a presenting symptom in idiopathic hypoparathyroidism. J Neurol Neurosurg Psychiatry. Jul 1977;40(7):692-4. [Medline].
Doorenbos CJ, Ozyilmaz A, van Wijnen M. Severe pseudohypocalcemia after gadolinium-enhanced magnetic resonance angiography. N Engl J Med. Aug 21 2003;349(8):817-8. [Medline].
Mark PB, Mazonakis E, Shapiro D, Spooner RJ, Stuart C Rodger R. Pseudohypocalcaemia in an elderly patient with advanced renal failure and renovascular disease. Nephrol Dial Transplant. Jul 2005;20(7):1499-500. [Medline].
Prince MR, Choyke PL, Knopp MV. More on pseudohypocalcemia and gadolinium-enhanced MRI. N Engl J Med. Jan 1 2004;350(1):87-8; author reply 87-8. [Medline].
Jung RT, Davie M, Hunter JO, Chalmers TM. Ultraviolet light: an effective treatment of osteomalacia in malabsorption. Br Med J. Jun 24 1978;1(6128):1668-9. [Medline].
Norman JG, Politz DE. Safety of immediate discharge after parathyroidectomy: a prospective study of 3,000 consecutive patients. Endocr Pract. Mar-Apr 2007;13(2):105-13. [Medline].
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