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Hypercalcemia

General

Hypercalcemia (working definition) is a total calcium greater than than the normal range for age. In most situations, use the total calcium for defining hypercalcemia and the ionized calcium for confirmatory purposes. However with an increased serum albumin or acid base disturbance, rely more on the ionized calcium. Please note: normal ranges may vary depending on the age of the patient, assay used and the laboratory. The following is meant as a guideline for the initial management, investigation and referral of patients with hypercalcemia.

  1. Severe (Urgent)

    A serum total calcium >or equal to 2.9mmol/L. Send the patient to the hospital emergency room and speak with the Endocrinologist or Alternate on call.

    Recommendations
  1. Treatment
    There are 2 treatment options. The most appropriate option will depend on the level of the serum calcium as well as patient factors and the availability of pharmaceutical agents.
    Option 1
    • Intravenous infusion of 0.9% Saline at 1- 1.5 times maintenance
    • Establish baseline electrolytes and a good state of hydration then Furosemide (Lasix) at a dose of 0.5-1 mg/kg/dose IV. If, 4- 6 hours after the 1st dose, the serum calcium remains above 2.9 mmol/l , a second dose of lasix can be given If, 4-6 hours after the 2nd dose, the serum calcium remains above 2.9 mmol/l , consider bisphosphonate/calcitonin (see below). Monitor serum electrolytes carefully
    • Calcitonin-Pamidronate or Zolendronate (see below for doses)

    Option 2
    • Intravenous infusion of 0.9% Saline at 1-1.5 maintenance
    • Calcitonin; 2-4 IU/kg subcutaneously every 6 hours x 3 doses only
    • Pamidronate 0.5 mg/kg IV over 4 hours (single dose) or Zolendronate 0.01-0.02 mg/Kg over 20 minutes (single dose)
  1. Investigations
      • Blood; total and ionized calcium, phosphate, alkaline phosphatase, 25 OH Vitamin D, 1,25 (OH) Vitamin D, PTH, electolytes and creatinine
      • Urine (random); calcium/creatinine ratio.
      • X ray left wrist.
  1. Consultation
      • Contact endocrine doctor or alternate on call to review treatment and investigations
      • Referral to Calcium Clinic - see below
  1. Moderately Severe
    A serum calcium level between 2.7mmol/L and 2.9mmol/L

    Recommendations
    1. Treatment
      In the symptomatic patient proceed with either option 1 or 2 as for severe hypercalcemia.
      In the asymtomatic or very mildly symptomatic patient, intravenous infusion of 0.9% saline/lasix may not be required. Consider initial management with increased oral sodium intake (2-4 meq/kg/day) (if no contraindications to this) in the form of 3% saline added to fluid intake. Oral fluid intake 1.5 times maintenance and fast track referral to Calcium Clinic (see below)
    2. Investigations
      As for severe hypercalcemia
    3. Consultation
      • Contact endocrine doctor or alternate on call to review treatment and investigations
      • Referral to Calcium Bone Clinic - see below
  1. Borderline
    A Serum calcium level between 2.5mmol/L and 2.7mmol/L 
    1. Treatment
      No specific treatment usually required.
    2. Investigations
      As for severe hypercalcemia
    3. Consultation
      • Referral to Calcium Bone Clinic - see below
      • Common Causes of Hypercalcemia - see References
      • Neonatal/Infantile Hypercalcemia
      • Hypercalcemia in children

To refer patients to Calcium Clinic at SickKids

Severe and moderately severe cases once

  • Initial treatment and investigations have been undertaken
  • Patient stabilized
  • Consultation appropriate for SickKids.

The referral to be faxed to 416-813-6192 with all results.