Hypercalcaemia

Data Gathering

• Assess severity
  • 2.60 – 3.00 – not usually a medical emergency
  • 3.00 – 3.50 – possible medical emergency
  • > 3.50 – usually a medical emergency

nb: other factors are important e.g. symptoms, renal function, speed of onset

• When to suspect hypercalcaemia
  • Symptoms
    • Bones – bone pain
    • Stones – renal stones
    • Abdominal groans – constipation, n&v
    • Psychiatric moans – depression, lethargy, confusion, psychosis
    • Others – polyuria, polydipsia (these are most specific)
• Causes
  • Primary hyperparathyroidism
  • Renal disease – tertiary hyperparathyroidism, treatment with vitamin D analogues
  • Malignancy – primary solid tumour, secondary in bone, haematological
  • Others – hyperthyroidism, sarcoidosis, vitamin D toxicity, medications (lithium, thiazide)
• Measure PTH
  • <15 ng/L
    • Non PTH dependent hypercalcaemia – malignancy, hyperthyroidism, vitamin D toxicity, sarcoid
  • 15-30 ng/L
    • Equivocal – PTH is neither clearly suppressed nor in the range expected with primary hyperparathyroidism – repeat
  • >30 ng/L
    • Causes
      • Primary hyperparathyroidism (most common cause)
      • Familial – MEN I, IIa, FHH
      • Tertiary hyperparathyroidism (advanced kidney disease)
      • Medications – Lithium

Clinical Management

• PTH-dependent hypercalcaemia
  • Investigations
    • Bloods – FBC, U+Es, LFTS, TFTs, Bone profile, PTH, Vitamin D
    • ECG
    • CXR
    • DEXA (if not done in past 3 years and patient not known to have osteoporosis)
    • Refer
      • Endocrine – confirmation of diagnosis, rule out familial, assessment for surgery
      • Renal – if kidney disease
• Others
  • Stop excessive dietary calcium
  • Stop thiazides
  • Lithium – discuss with endocrine/psychiatry before stopping
• Non PTH-dependent hypercalcaemia
  • If known cancer – refer to relevant hospital team
  • If underlying cancer not known, referral depends on history and other findings