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Management of Hypercalcaemia

For the management of hypercalcaemia in malignancy, or hypercalcaemia in palliative patients, see separate guidance available at www.palliativecareguidelines.scot.nhs.uk. 

This guideline has been adapted for local use. The original guideline is available at:

Walsh J, Gittoes N, Selby P, the Society for Endocrinology Clinical Committee. Society for Endocrinology Endocrine Emergency Guidance: Emergency management of acute hypercalcaemia in adult patients. Endocrine Connect 2016 vol 5, no. 5, G9-G11 published under Creative Commons 4.0 license (http://www.endocrineconnections.com/). Accepted for publication 3rd August 2016. All modifications from the original guideline have been denoted below by # and should not be taken as an endorsement by the original authors.

Introduction

Serum calcium concentration is tightly regulated within a normal reference range of between 2.2-2.6mmol/L.# Abnormalities of parathyroid function, bone resorption, renal calcium reabsorption or dihydroxylation of vitamin D may cause the regulatory mechanisms to fail and serum calcium to rise. Serum calcium is bound to albumin and measurements should be adjusted for serum albumin. Ninety percent of hypercalcaemia is due to primary hyperparathyroidism or malignancy.#

Adjusted calcium <3mmol/L: often asymptomatic and does not require urgent correction, however discuss with the endocrine team.#

Adjusted calcium 3-3.5mmol/L: may be tolerated if level has risen slowly, however may be symptomatic and prompt treatment is usually indicated.#

Adjusted calcium >3.5mmol/L: requires urgent correction due to the risk of dysrhythmia and coma.#

 

Clinical features of hypercalcaemia include:

  • Polyuria and polydipsia#
  • Anorexia, nausea and constipation
  • Mood disturbance, cognitive dysfunction, confusion and coma
  • Renal impairment
  • Shortened QT interval and dysrhythmias
  • Nephrolithiasis and nephrocalcinosis
  • Pancreatitis
  • Peptic ulceration
  • Hypertension
  • Cardiomyopathy
  • Muscle weakness.#

 

Assessment / monitoring

Investigation

  • History
    • Symptoms of hypercalcaemia and duration
    • Symptoms of underlying causes e.g. weight loss, cough
    • Family history
    • Drugs including supplements and over the counter preparations.
  • Examination: 
    • Assess for cognitive impairment
    • Fluid balance status
    • Look for underlying causes: neck, respiratory, abdomen, breasts, lymph nodes.#
  • ECG: Look for shortened QT interval or other conduction abnormalities.
  • Bloods: Bone profile, PTH, U&Es.#

Drug therapy / treatment options

Rehydration

  • Sodium chloride IV 0.9% 4-6L in 24 hours. Periodically review and tailor fluid regimen to the individual as appropriate.#
  • Use caution in renal impairment, elderly patients and heart failure patients. Monitor for fluid overload.#
  • Loop diuretics are not effective in lowering calcium and only to be used if fluid overload develops.#
  • Dialysis may need to be considered in severe renal failure.#

Bisphosphonates IV

This should be considered if further treatment is required after IV sodium chloride.#

  • Bisphosphonates IV:
    • Zoledronic acid 4mg over 15minutes or
    • Pamidronate 30-90mg at 20mg/hour - dose depends upon severity of hypercalcaemia, see manufacturer's summary of product characteristics (SPC) for guidance.#

N.B. Neither agent is licensed for use in non-tumour induced hypercalcaemia.#

  • Give more slowly and consider dose reduction in renal impairment, see relevant SPC for further details.#
  • Monitor serum calcium response which will reach a nadir in 2-4 days and maintain adequate hydration throughout.#
  • Hypocalcaemia may ensue if PTH suppressed or there is vitamin D deficiency.#

Second-line treatments

There are other medicines that can be considered on a case by case basis (e.g. glucocorticoids as they inhibit 1,25OH vitamin D production, calcimimetics, parathyroidectomy) but seek specialist advice.#

 

Guideline reviewed: February 2023

Page last updated: March 2023