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PDAT3 > 7 - HYPERcalcemia > Flashcards

7 - HYPERcalcemia Flashcards

1
Q

Normal Serum Calcium

A

8.5 - 10.5
mg/dL

Half calcium is protein bound
15% bound to anions
40% bound to albumin

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2
Q

Normal Ionized Serum Calcium

A

4.4-5.5
mg/dL

~1/2 of total serum Ca

does NOT vary with ALBUMIN

Free Ca+

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3
Q

Corrected Calcium Claculation

A

Corrected Ca+ =

( Total Measured Ca+ ) + 0.8 (4 - Measured Serum Albumin )

Normal Serum Albumin = 4 mg/dL

This can OVERestimate Ca+,

  • *Ionized Ca+** should be obtained if patient is
  • *critically ill** or if total is low <7.5mg/dL
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4
Q

Relationship between
Calcium & PTH

A

Calcium has a NEGATIVE feedback on PTH
via Calcium sensing Receptor

*LOW CALCIUM* –> PTH SERGE ^^

Bones
Stim Osteoclast –> bone REsorption
inhibits osteoBlasts & bone formation

Kidneys
INCREASE reabsorption of calcium, less calcium clearance
Stimulates hydroxlase –> INCREASE Vitamin D production

Gut
indirectly increases calcium absorption via stim of VITAMIN D production

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5
Q

Relationship Between
Calcium & Calcitonin

A

High Calcium** –> **High CALCITONIN

Hormone that INHIBITS osteoclastic bone resorption (breakdown)

Mechanism to return calcium levels to NORMAL, when too HIGH

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6
Q

Relationship between
Calcium & VITAMIN D

A

High phos / Low Ionized Ca+ leads to:
Active Vitamin D (Calcitriol)
VVVV
INHIBITS PTH Release
VV
INCREASE SERUM CALCIUM by:

Stimulating Calcium RELEASE from bones

Enhance Ca+ absorption in GI tract

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7
Q

HYPERcalcemia

Value?

A

Total Serum Calcium
> 10.5 mg/dL

Ionized Calcium
> 5.4 mg/dL

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8
Q

Etiology of HYPERcalcemia

Calcium in Circulation > Excretion of Ca+ (Urine / Bone desposition)
Caused by:
Accelerated Bone Resorption
Excessive GI absorption
Decreased Renal Excretion of Calcium

A

PRIMARY or SECONDARY HYPERthyroidism // MALIGNANCY
= 90% of HYPERcalcimia Cases

Drug Induced

Endocrine Disorders
Addison’s / Acromegaly / Throtoxicosis

Granulomatous Disorders
Sarcoidosis / Tuberculosis

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9
Q

Primary HYPERparathyroidism

A

MAJOR Cause of HYPERcalcemia

Caused by:
Parathyroid ADENOMA
innapropriate increase in PTH Secretion –> HIGH Ca+

High Normal Values <11mg/dL
w/ intermittent HYPERcalcemia

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10
Q

Secondary HYPERparathyroidism

A

MAJOR Cause of HYPERcalcemia

Associated with:
HYPERplasia of GLANDS

Observed in patients with CKD

Adaptive disease in the Setting of CKD:
Inability to activate VITAMIN D + Increased PHOS

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11
Q

Tertiary HYPERparathyroidism

A

Advanced RENAL failure –> Parathyroid Hyperplasia

May resolve after kidney transplant

Parathyroidectamy might be needed to help PTH levels

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12
Q

HIGH PTH EFFECTS
HYPEParathyroidism

A

KIDNEY
INCREASE renal absorption of CALCIUM
INCREASE renal EXCRETION of PHOS
Stimulate synthesis of calcitriol

INTESTINE
indirectly INCREASES absorption of Ca/P in Small Intestine

BONE
Stimulates osteoclast to RESORB bone –> ↑​Ca+
inhibits osteoblast & bone absorption

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13
Q

Malignancy
effects on Calcium

A

Also accounts for ~90% of HYPERcalcemia

Calcium Levels > 13mg/dL

Solid Tumors + Leukemia

VVVV
INCREASED
Bone RESORPTION&GI ABSORPTION

high Ca

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14
Q

Drug Induced HYPERcalcemia

A

DISCONTINUE OFFENDING AGENTS

THIAZIDE DIURETICS
most common –> increase renal tubular reabsorption of CA
block NA rabsorption –> INCREASE Ca reabsorption

  • *Lithium**
  • *Resets PTH** hormone –> increased PTH

Vitamin A
INCREASE bone resorption (stim osteoclasts)

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15
Q

Moderate + Chronic HYPERcalcemia

Levels / Symptoms

A

12-14

GI:
Anorexia / N+V / Constipation

Renal:
PolyUria / PolyDipsia

MUSCLE WEAKNESS

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16
Q

Severe / Life-Threatening (ACUTE)
HYPERcalcemia

Levels / Symptoms

A

>14** or **RAPID INCREASE IN Ca
Any level can be considered ACUTE, as long as there is:
Rapid/Substantial Rise in Ca and S/Sx present

the ACUITY of the RISE in Calcium –> determines therapy

Profound DEHYDRATION

Renal Failure / CV+Neuromuscular Dysfunction / COMA

17
Q

Signs / Symptoms of
CHRONIC HYPERcalcemia

A

Long Standing HYPERcalcemia:
HYPERparathyroidism / Sarcoidosis / CKD

Calcium Desposition in BV & organs
deposits in artherosclerotic lesions –> heart disease
deposit in skin –> calciphylaxis
deposit in kidney –> nephrocalcinosis (permanent kidney dmg)

18
Q

HYPERCalcemia TREATMENT

CHART

A
19
Q

Treatment for MILD+Asymptomatic
HYPERcalcemia

<12 mg/dL

A

Reduce dietary Calcium
<400 mg/day
by avoiding food/diet high in calcium

AVOID:
Thiazides / Lithium / Vitamin D

Stay well hydrated

Avoid IMMOBILIZATION –> precipitation

20
Q
  • *Moderate +**
  • *HYPERcalcemia Treatment**

12-14 mg/dL

A

ASYMPTOMATIC –> treat like MILD

ACUTE RISE IN CA –> TREAT as SEVERE

21
Q

Treatment for SEVERE
HYPERCalcemia

  • *>15 mg/dL**
  • *Symptomatic // ACUTE RISE**
A

PARENTERAL THERAPY

NS 0.9% + Loop Diuretic
Volume Expansion // Increase Ca+ EXCRETIOn

Calcitonin
used in SYMPTOMATIC patients –> rapidly DECREASES serum Ca+

Bisphosphonates
provides a sustained effect in lowering calcium

  • *Dialysis**
  • *last resort**, make sure there is NO CA in dialysis fluid
22
Q

SALINE
Dose / MoA / ADR

Severe HYPERcalcemia Treatment

A

given with LOOP DIURETICS to help increase Ca excretion

Normal Saline 0.9%
corrects volume depletion –> euvolemia

200-300 ml/hr
adjusted to maintain UOP = 100-150 ml/hr

ADR:
Fluid Overload / Edema / Electrolyte abnormalities

Considerations:
Severity / age / comordities / no diuretics with renal/heart failure

23
Q

CALCITONIN

Severe HYPERcalcemia Treatment​

A

Works VERY RAPIDLY –> deceease serum calcium

Used for:
Acute + SYMPTOMATIC patients

Hormone from Thyroid

INHIBITS Osteoclatic Bone Resorption
(bone breakdown)

Plasma concentrations are
INCREASED when ionized Ca is HIGH

24
Q

CALCITONIN

Dose / MoA / ADR

Severe HYPERcalcemia Treatment

SYMPTOMATIC PATIENTS

A
  • Antagonizes PTH* // Decrease Bone Resorption
  • *Increase calcium EXCRETION**

4 IU/k_g** **IM/SC**
works very RAPIDLY ↓**Ca 1-2 mg/dl within 4-6 hours**
–> DOSE AGGRESIVELY
**If Responsive –> REPEAT q6-12 hours** **@4-8IU/kg_

ADR:
Nausea / HYPERsensitivity / Tachyphylaxis

25
Q

BISPHOSPHONATES

Severe HYPERcalcemia Treatment

A

Adsorb to surface of bone hydroxyapatitie
INHIBIT calcium release –> inhibit osteoclasts resorption

Most effective in HYPERcalcemia from:
Excessive Bone Resorption (vs other etiology)

MORE POTENT than Calcitonin + Saline

LAST LONG = 2-4 WEEK duration

Drug specific Dosing:
Zolendronic Acid / Pamidronate / Ibandronate

26
Q

BISPHOSPHONATES

Dose / MoA

Severe HYPERcalcemia Treatment

A

Inhibit Calcium Release = inhibits osteoclasts

  • *SLOW Infusion Rate** for patinets with Renal Dysfunction
  • *2-4 Week duration**
  • *ZOLENDRONIC ACID**
  • *4mg IV** over 15 minutes
  • *MOST POTENT** = PREFERRED, renal toxicity with 8mg dose

Pamidronate
60-90mg IV over 2 hours, fever

Ibandronate
2mg IV over 2 hours, dyspepsis / backpain

27
Q

BISPHOSPHONATES

ADRs

Severe HYPERcalcemia Treatment

A

Osteonecrosis of JAW
w/ repetitive use

Acute Phase Reactions
bone pain / fever / flu like symptoms

AVOID if CrCl <30 ml/min // ESRD = renal dosage

28
Q

Preventing HYPERcalcemia Recurrance in
MALIGNANCY

A

lower tumor burden

Metastatic BONE Disease:

Administer

  • *PAMIDRONATE / ZOLENDRONIC ACID**
  • *q 3-4 weeks**

Denosumab
for refractory HYPERcalcemia
no restriction in CKD patients, effect seen in 2-4 days
60 g SC w/ repeat dosing based on response

29
Q

Role of GLUCOCORTICOIDS

in HYPERcalcemia

A

Used in:
Chronic Granulomatous Diseases = Sarcoidosis

Decreased Intestinal Calcium Absorption

Decreased Calcitriol Production
by activated mononuclear cells in lungs / lumph nodes

PREDNISONE 20-40 mg/day
effect in 2-5 days, can last days - weeks

30
Q

HYPERcalcemia in HYPERparathyroidism

A

Usually CHRONIC + Asymptomatic

Long standing consequences:
Osteoporosis / Calcifications in organ systems

Use CALCIMEMETICS:

Sensipar = Cinacalcet

Parsabiv = Etelcalcetide

31
Q

SENSIPAR

For Hypercalcemia in Hyperparathyroidism

A

Cinacalcet

Decrease PTH
by increasing sensitivity of calcium receptor on PT gland

30 - 60 - 90 mg QD WF

ADR:
decrease in SERUM Ca+ // NVD
ensure corrected Ca > 7.5mg/dL before dose titration
titration is q3-6 weeks

strong inhibitor of CYP2D6

32
Q

PARSABIV

For Hypercalcemia in Hyperparathyroidism​

A

Etelcalcetide

Binds to Calcium Sensing Receptor
on PT gland & enhances activation by serum calcium

5 mg IV bolus
3 x Week @ end of hemodialysis
Dose Adjustment:
Titrate dose in 2.5 or 5mg increments no more than < q4 weeks
Conversion from Cinacalcet/Sensipar:
D/C Sensipar for >7 days prior to initiating

ADR = Serum Calcium / adj dose if Ca <7.5mg/dL

DO NOT GIVE if HEMODIALYSIS session is MISSED
If miss >2 weeks of doses –> restart @ 5mg IV 3 x week

33
Q

Calcitriol Induced HYPERcalcemia

TREATMENT of HYPERvitaminosis D

A

TRIOL = TRYING = ACTIVE VITAMIN D

Lasts 1-2 days due to short half life

D/C Calcitriol

INCREASE FLUID INTAKE / IV HYDRATION
w/ SALINE

34
Q

Calcidiol Induced HYPERcalcemia

TREATMENT of HYPERvitaminosis D

A

-Diol - Lasts LONGER

AGGRESIVE THERAPY

Glucocorticoids

IV Bisphosphonates if symptomatic

PDAT3 (23 decks)

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