Hypercalcemia

Good afternoon, everyone!

Thank you Frank and Sam, for sharing a case of a middle-aged woman with history of sarcoidosis, who presented with symptomatic and severe hypercalcemia. Our Endocrinology discussants taught us some awesome pearls on evaluation & management of hypercalcemia.

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KEY PEARLS

 

  1. Always check a serum albumin (albumin is a negatively charged protein that binds to Ca2+) to calculate out corrected calcium. 

  2. In cases of hypercalcemia, a chloride/phosphate ratio of > 33 has a high sensitivity and specificity for hyperparathyroidism.

  3. Always order a PTH first to determine PTH-dependent vs PTH-independent causes of hypercalcemia.

4)    Even for cases of severe (>14 mg/dL or symptoms) hypercalcemia, aggressive IV fluid hydration is often adequate in regulating levels & symptoms of hypercalcemia. For pharmacologic treatment of hypercalcemia (refractory to hydration alone), use calcitonin or bisphosphonates.

 

Flashback to ZSFG Chiefs’ pearls from earlier this year:

 

      PTH-related causes of hypercalcemia

 

  • primary hyperparathyroidism (high PTH)

  • inherited variants of MEN

  • familial hypocalciuric hypercalcemia (mildly elevated PTH)

  • familial isolated hyperparathyroidism

  • hyperparathyroidism-jaw tumor syndrome (obviously)

  • tertiary hyperparathyroidism/renal failure

    Non-PTH related causes of hypercalcemia

 

  • malignancy

  • vitamin D/A excess

  • chronic granulomatous disorders

  • medications (i.e. thiazide diuretics, lithium), vitamins, herbals

  • milk alkali (TUMS)

  • adrenal insufficiency

  • acromegaly

  • pheochromocytoma, and the list goes on…

    Pharmacologic Treatment of Hypercalcemia

     

  • Calcitonin: administered IM or subcutaneously every 12 hours
    : Very well tolerated, and works rapidly (within 4-6 hours)!
    : However, efficacy is limited to first 48 hours, even with repeated doses, thought to be due to receptor downregulation.

  • Bisphosphonates: More potent than calcitonin, but the maximum effect occurs in 2-4 days. Hence, are often used in conjunction with saline and/or calcitonin.
    : Think about the rare side effect of osteonecrosis of the jaw in patients with repetitive use of IV bisphosphonates!

 


Evernote Link: https://www.evernote.com/shard/s338/sh/a9c0db44-ce19-4896-9664-ac3e70541bf4/fff23590ad930072b9311a6d9883d232

 

 

 

 

 

 

 

 

 

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