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Electrolytes and Acid-base disorders > Hypercalcaemia > Flashcards

Hypercalcaemia Flashcards

1
Q

Normal calcium level

A

2.2 to 2.7mmol/L

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2
Q

Hypercalcaemia >>> main causes

A
  • Malignancy
    • 80% due to PTHrP of NSCLC (squamous)
    • Multiple myeloma, bone metastasis (high ALP)
      • Osteolytic hypercalcaemia
      • Calcitriol mediated hypercalcaemia
      • Ectopic PTH >> hypercalcaemia
  • Primary hyperparathyroidism (high ALP, low PO4)
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3
Q

Hypercalcaemia >>> other causes

A
  • Hormonal >>>
    • Acromegaly
    • Thyrotoxicosis
    • Addison’s disease
    • Tertiary hyperparathyroidism (high PO4)
  • Drugs >>>
    • Thiazides (No other diuretics)
    • Ca containing antacids
    • Vitamin D intoxication (high PO4)
  • Bone >>>
    • Paget’s disease of the bone; (raised ALP)
    • ​​Usually paget’s has normal Ca level; but prolonged immobilisation > high ca
  • Granulomas >>>
    • Sarcoidosis (Granuloma produces 1,25 vit D → raises Ca; Steroid Tx to reduce Ca)
    • Tuberculosis, Histoplasmasis (less common than sarcoidosis); Granuloma produces 1,25 vit D → raises Ca
  • Others >>>
    • Milk-alkali syndrome
    • Dehydration; (So, Tx is IV saline)
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4
Q

Hypercalcaemia >>> overall causes

A
  • Main causes >>>
    • Malignancy
      • 80% due to PTHrP of NSCLC (squamous)
      • Multiple myeloma, bone metastasis (high ALP)
        • Osteolytic hypercalcaemia
        • Calcitriol mediated hypercalcaemia
        • Ectopic PTH >> hypercalcaemia
    • Primary hyperparathyroidism (high ALP, low PO4)
  • Hormonal >>>
    • Acromegaly
    • Thyrotoxicosis
    • Addison’s disease
    • Tertiary hyperparathyroidism (high PO4)
  • Drugs >>>
    • Thiazides (No other diuretics)
    • Ca containing antacids
    • Vitamin D intoxication (high PO4)
  • Bone >>>
    • Paget’s disease of the bone; (raised ALP)
    • ​​Usually paget’s has normal Ca level; but prolonged immobilisation > high ca
  • Granulomas >>>
    • Sarcoidosis (Granuloma produces 1,25 vit D → raises Ca; Steroid Tx to reduce Ca)
    • Tuberculosis, Histoplasmasis (less common than sarcoidosis); Granuloma produces 1,25 vit D → raises Ca
  • Others >>>
    • Milk-alkali syndrome
    • Dehydration; (So, Tx is IV saline)
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5
Q

Hypercalcaemia: Features

A
  • <2.8 >>> thirst, polyuria, polydipsia, mild cognition loss
  • 2.8 to 3.5mmol/L >>> muscle weakness, constipation, anorexia, nausea, fatigue (added)
  • >3,5mmol/L >>> vomiting, dehydration, cardiac arrhythmia, coma, pancreatitis (added)
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6
Q

The differentiating features between MGUS (Monocloncal gammopathy of undermined significance) and multiple myeloma

A

MGUS doesn’t have complications, such as: immune paresis, hypercalcaemia, bone pain

which are the features of multiple myeloma

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7
Q

Hypercalcaemia >>> ECG

A

Short QT

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8
Q

ECG features: hypocalcaemia vs hypercalcaemia

A
  • Hypocalcaemia: Long QT
  • Hypercalcaemia: Short QT

​See: Vice-Versa

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9
Q

Bisphosphonate treatment >>> ECG

A

Initial Tx with bisphosphonate rapidly develops hypocalcaemia (low Ca) and ECG shows corrected long QT

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10
Q

Hypercalcaemia >>> first useful test (and why) ?

A

PTH (Parathyroid hormone levels)

Because, Malignancy and primary hyperparathyroidism are two most common causes of hypercalcaemia

  • Raised PTH + low PO4 >>> Dx: Primary hyperparathyroidism (More common than tertiary)
  • Raised PTH + high PO4 + CKD/CRF >>> Dx: Tertiary hyperparathyroidism
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11
Q

Effect of bisphosphonate on calcium level

A

It lowers calcium level

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12
Q

Hypercalcaemia: management

A
  • Initial TOC: IV normal saline 3-4litres/day (to rehydrate)
  • Next Tx: Bisphosphonate (e.g. Pamidronate)
    • Given after rehydration
    • It takes typically 2-3days to work, with maximal effect seen at 7days
    • When it develops hypocalcaemia >>> corrected long QT in ECG
  • ​​Other Treatment options:
    • Calcitonin (Quicker effect than bisphosphonates)
    • Steroids (used in sarcoidosis to reduce calcium)
    • Furosemide (limited role here; only useful if patient cannot tolerate aggressive fluid rehydration)
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13
Q

Hypercalcaemia: initial treatment

A

IV normal saline 3-4litres/day (to rehydrate)

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14
Q

Hypercalcaemia: treatment after rehydration

A

Bisphosphonates (e.g. Pamidronate)

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15
Q

Which does reduce calcium level more quickly than bisphosphonates?

A

Calcitonin

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16
Q

Sarcoidosis induced hypercalcaemia >>> TOC

A

Steroids

17
Q

If patient cannot tolerate aggresive fluid replacement/rehydration >>> useful treatment

A

Furosemide

18
Q

Hypercalcaemia >>> Advices during discharge

A
  • Maintain a good hydration
    • Increase fluid intake
    • Drink 3-4L fluid per day
  • Avoid vitamin supplements or drugs that may cause hypercalcaemia
    • ​Thiazides
    • Ca containing antacids etc.)
  • Encourage mobilisation

Electrolytes and Acid-base disorders (18 decks)

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