Further Outpatient Care
Daily calcium intake should be limited, and restriction of vitamin D (sunlight, dairy) may be warranted in certain disorders.
Further Inpatient Care
Admit any patient requiring treatment for hypercalcemia.
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Continue the previously mentioned medications as needed.
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Continue an appropriate workup for the etiology of hypercalcemia.
For neonates, specifically, Oski recommends 5% dextrose (D5) in one-half isotonic sodium chloride solution with 30 mEq/L potassium chloride at 2 times the maintenance dose along with 2-3 mg/kg/d furosemide and adequate phosphate supplementation to maintain normal levels. [17] Strongly consider surgical correction of primary hyperparathyroidism.
Inpatient & Outpatient Medications
Long-term therapy can begin while the patient is in the hospital and continue following discharge.
Corticosteroids are helpful in certain disorders, particularly malignancy-associated hypercalcemia, granulomatous disease, or vitamin D ingestion; and they can be given either IV or orally as prednisone in doses of 40-60 mg/m2/d or 1.5-2 mg/kg/d to inhibit osteoclast action and decrease intestinal calcium absorption.
Aminohydroxypropylidene (APD) can induce remissions of malignancy-associated hypercalcemia.
If serum phosphate is low, intravenous (IV) phosphorus is no longer recommended because of the risk of intravascular precipitation with calcium; however, oral phosphate supplementation is recommended because this binds calcium in the intestine and diminishes calcium absorption. The dose is 1-3 g/d for an adult-sized person. Phosphate is contraindicated in renal failure and requires 2-3 days before it becomes effective.
Bisphosphonates may also be continued as outpatient medications. One should consider alendronate as an oral preparation. However, note that no pediatric experience is noted.
Indocin may be of some use in certain disorders that lead to hypercalcemia.
Transfer
As in any patient, transfer is acceptable when patient is stable or when a higher level of care is required. However, consider the possibility of coma or cardiovascular collapse in a patient with an excessively high calcium level. Begin close observation/therapy before transfer.
Deterrence/Prevention
Carefully monitor patients with risk factors for hypercalcemia, such as known malignancy, thiazide diuretic use, total parenteral nutrition, retinoid use for acne, or lithium use.
Counsel patients to consume adequate phosphate and to avoid excessive calcium-containing antacids, vitamin D, and herbal preparations with vitamin A.
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Investigations flowchart.
Tables
Laboratory Test |
Reference Range |
Normal Response to Increased Calcium |
Serum calcium |
8.5-10.2 mg/dL |
NA |
Ionized calcium |
1-1.3 mmol/L |
NA |
PTH (intact) |
10-55 pg/mL* |
Decrease |
Serum phosphate |
Age-dependent |
Increase |
1,25-dihydroxyvitamin D |
36-108 pmol/L |
Decrease |
Alkaline phosphatase |
68-217 U/L |
Normal |
Urine calcium |
4 mg/kg/d |
Increase |
Urine Ca/Cr ratio |
See note† |
Increase |
Urine cAMP‡ |
< 5 mol |
Decrease |
*Note that 1 mmol/L equals 4 mg/dL. †In infants younger than 7 months, the reference range is less than 0.86; in infants aged 7-18 months, the reference range is less than 0.6. By age 6-7 years, the adult reference range of less than 0.21 is reached.‡The urine cAMP level generally parallels the PTH level. |
||
Condition |
Serum Phosphorus |
Serum Alkaline Phosphatase |
Urine Calcium |
Urine Phosphate |
PTH |
Hyperparathyroidism |
Low |
Normal-high |
High* |
High |
High |
Vitamin D excess |
Normal-high |
Low |
High |
High |
|
Malignancy |
Often low |
High † |
Variable |
High |
|
Granulomatous disease |
Normal-high |
Normal-high |
High |
Normal |
|
Milk alkali syndrome |
Normal-high |
Normal |
Normal |
Normal |
|
FHH |
Normal or low |
Normal |
Low (< 200mg/d) |
Normal |
Low |
*67% of the time † Except hematologic malignancies, in which alkaline phosphatase is normal |
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