Hypercalcemia Flashcards
define hypercalcemia
ionized calcium above 1.95
what causes hypercalcemia
imbalance between renal excretion, bone resorption and intestinal absorption
this balance is regulated by PTH, vitamin D and calcitonin
list the 6 general causes of hypercalcemia
- parathyroid related
- most likely asymptomatic - malignancy related
- vitamin D related
- increased bone turnover
- renal failure
- medications
what are the types of parathyroid related hypercalcemia and how do you ask about them
primary hyperparathyroidism–> any lump in your neck? (too much PTH being produced)
familial hypocalciuric hypercalcemia (benign, autosomal dominant, enhanced renal tubular resorption)–> ask about family history
can be related to LITHIUM therapy–> ask about meds
how does malignancy result in hypercalcemia
can result from metastatic disease to bone, like from breast cancer
in lung or kidney cancers, can be from PTH-related protein activity
can result from hematologic malignancies like MULTIPLE MYELOMA, leukemia and lymphona –> ask aboout changes in weight, fever, night sweats
how does vitamin D shit result in hypercalcemia
vitamin D intoxication–> supplemental vitamin D intake?
granulomatous disease–> sarcoidosis, TB
lymphoma
what states of increased bone turnover can cause hypercalcemia
hyperthyroidism
immobilization
vitamin A intoxication
what medications can cause hypercalcemia
lithium thiazide diuretics tamoxifen antacids (milk alkali syndrome?) large doses vitamin D
what % of people have no signs or symptoms of hypercalcemia
80%
what are the KEY symptoms of hypercalcemia
moans
groans
stones
psychiatric overtones
non specific symptoms: muscle weakness, depression, memory impairment, anorexia, polyuria, polydipsia, kidney stones
what to ask on history to elicit hypercalcemia
calcium level low, high? what was the repeat level?
general–> fatigue, depression, energy, mood?
GI–> appetite? nausea, vomiting? constipation? stomach ulcers?
GU–> urinating more than normal? kidney stones?
MSK–> weakness? bone pain? joint pain?
symptoms of malignancy–> cough? breast mass? headache? constitutional symptoms?
family history
what med causes milk alkali syndrome
antacids
what to pay attention to on physical exam for hypercalcemia
commonly BP is elevated
confusion on MSE
palpate for cervical lymphademopathy, lump in neck from thyroid
signs of malignancy–breast exam, lung, abdo, lymph nodes, bones tenderness (if present, get XR)
check muscle tone, power, reflexes for hyporeflexia
what is the first test for the workup for hypercalcemia
PTH level
how does calcium change with changes in albumin
corrected calcium: calcium increases by 0.2 for every drop of albumin by 10
what tests should you order, other than PTH, to work up hypercalcemia
ionized calcium or corrected calcium
basic metabolic panel including lytes, magnesium, phosphate
Hb
ESR
CXR for hilar LAD
serum T3 and T4 and TSH (progressive testing)
serum vitamin D level
how do you rule out mets in hypercalcemia
ALP
bone scan
spinal XR
what is the immediate management of hypercalcemia
hydration with IV fluids/ECF volume expansion
–> this will be sufficient for mild cases
saline diuresis–> give NA as sodium promotes calcium excretion in the urine by competing with tubular reabsorption
loop diuretics–> unlikely to be of great benefit (lasix does increase urinary calcium excretion but large doses are needed like up to 80mg every 8 hours which results in large water losses which can compromise renal function)
other than fluids, saline diuresis and considering lasix, what are some other treatments for hypercalcemia
- calcitonin –> inhibits osteoclast resorption of bone
- bisphosphonates–> inhibit growth and dissolution of hydroxyapatitic crystals
- corticosteroids–> only in certain cases like vitamin D intox and granulomatous disease
what is the principal agent used in hypercalcemia management
bisphosphonates–> PAMIDRONATE
can be given as one single IV dose over 24 hours
