Further Outpatient Care
See the list below:
-
Daily calcium intake should be limited, and restriction of vitamin D (sunlight, dairy) may be warranted in certain disorders.
Further Inpatient Care
See the list below:
-
Admit any patient requiring treatment for hypercalcemia.
Continue the previously mentioned medications as needed.
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. [15] Strongly consider surgical correction of primary hyperparathyroidism.
Inpatient & Outpatient Medications
See the list below:
-
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
See the list below:
-
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
See the list below:
-
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.
Complications
See the list below:
-
Primarily ectopic calcifications may occur (see Physical).
Prognosis
See the list below:
-
Hypercalcemia is frequently noted during laboratory testing while the patient is asymptomatic or mildly symptomatic. Prognosis depends on the underlying disorder.
-
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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