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Hypercalcemia A diagnostic and treatment approach

Hypercalcemia A diagnostic and treatment approach

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Hypercalcemia A diagnostic and treatment approach

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  1. Hypercalcemia A diagnostic and treatment approach UCI Internal Medicine – Mini Lecture

  2. Objectives • Understand the most common etiologies • Have a clear diagnostic plan • Understand acute management

  3. Initial evaluation • A 68 year-old female with no PMH or home meds is brought to the ER by family with altered mental status, nausea, and diffuse bony pain.

  4. Initial Evaluation • VS unremarkable. A&Ox1, tries to get out of bed and is distracted. Rest of exam is normal. 13 12 139 111 12 7.3 106 22 1.4 104 290 12 3.8 20 1 39 4 0.4 21 1.8 Diff wnl Corrected Calcium = (0.8 * (Normal Albumin - Pt's Albumin)) + Serum Ca

  5. Calcium reminders: • Absorbed through small intestine via a vitamin-D dependent pump • Excreted by the kidney • PTH: production of active Vitamin D, renal reabsorption and osteoclast activity

  6. Diagnostic Approach • PTH-mediated? • PTHrp? • Excess vitamin D? • Something else? (eg: genetic, MM)

  7. Diagnostic Approach

  8. Treatment • Mild (<12): No acute tx necessary • Avoid thiazides and lithium, volume depletion • Low calcium diet • Moderate (12-14): May or may not require tx

  9. Severe Hypercalcemia (>14) • Normal Saline (UTD recommends 200cc/hr, adjust for UOP 100-150cc/hr) • With Lasix as necessary • Calcitonin 4 IU/kg Q12 hrs (if Ca>14) • Cancer: Bisphosphonates (Reclast4mg IV over 15 mins) • Dialysis if these fail Monitor with Q8 serum calcium levels

  10. Treat Underlying Cause • Multiple Myeloma • Squamous Cell Cancer • Gynecologic Cancer • Sarcoidosis • Tuberculosis • Thyrotoxicosis • Pituitary Adenoma • Multiple Endocrine Neoplasia

  11. The case • Admitted to medicine for IVF • PTH 77 (normal 11-55); Urinary calcium 425mg/day • Tc99m-sestamibi demonstrated a single parathyroid adenoma • Referred to surgery for parathyroidectomy

  12. Take home points • Hypercalcemia can present asymptomatically or with very vague symptoms (stones, bones, groans…) • Still worth treating (risk for nephrolithiasis, arrhythmias, vascular calcification)

  13. Take home points • 1° hyperparathyroidism and malignancy are the most common causes • Check PTH first. If not elevated, check vitamin D (both 25-OH and 1,25-OH) • Treat all symptomatic patients with IVF