Management of Hypercalcemia

Introduction

Hypercalcemia is a condition characterized by elevated serum calcium levels, which can result from various underlying disorders. Effective management requires an understanding of its pathophysiology, causes, and therapeutic interventions.

Causes of Hypercalcemia

• Primary hyperparathyroidism
• Malignancy-associated hypercalcemia
• Vitamin D intoxication
• Granulomatous diseases (e.g., sarcoidosis, tuberculosis)
• Medication-induced (e.g., thiazide diuretics, lithium)
• Immobilization-related calcium release

Pathophysiology

Hypercalcemia results from excessive calcium absorption, increased bone resorption, or impaired renal excretion. Parathyroid hormone (PTH) and vitamin D play crucial roles in calcium homeostasis. In malignancy-associated hypercalcemia, tumor-produced factors like parathyroid hormone-related protein (PTHrP) stimulate osteoclastic bone resorption.

Clinical Presentation

Symptoms of hypercalcemia vary by severity:

• Mild: Fatigue, constipation, polyuria
• Moderate: Muscle weakness, nephrolithiasis
• Severe: Confusion, cardiac arrhythmias, coma

Management

Initial Stabilization

• IV hydration with isotonic saline to enhance renal calcium excretion
• Loop diuretics (e.g., furosemide) post-hydration to further decrease calcium levels

Pharmacological Therapy

• Bisphosphonates (e.g., pamidronate, zoledronic acid) – inhibit osteoclast-mediated bone resorption
• Calcitonin – provides short-term calcium lowering
• Glucocorticoids – useful in vitamin D intoxication and granulomatous diseases
• Denosumab – used for refractory cases, particularly malignancy-associated hypercalcemia

Treatment of Underlying Causes

Addressing the root cause is crucial:

• Parathyroidectomy for primary hyperparathyroidism
• Oncologic treatment for malignancies
• Discontinuation of causative medications

Conclusion

Hypercalcemia management requires prompt intervention to prevent complications. Targeted therapy based on underlying etiology ensures optimal outcomes.