How to correct hypocalcemia?

From the Guidelines

To correct hypocalcemia, administer intravenous (IV) calcium gluconate immediately, followed by oral calcium supplementation and vitamin D, as this approach is supported by the most recent and highest quality study 1.

Correction of Hypocalcemia

The treatment of hypocalcemia involves immediate correction with IV calcium gluconate, followed by long-term management with oral calcium supplements and vitamin D.

• Give 1-2 grams of calcium gluconate (10-20 mL of 10% solution) IV over 10-20 minutes.
• Follow this with a continuous IV infusion of calcium gluconate at 0.5-1.5 mg/kg/hour.
• Simultaneously, start oral calcium supplementation (calcium carbonate 1000-2000 mg three times daily) and oral vitamin D (calcitriol 0.25-0.5 mcg twice daily) to help maintain calcium levels long-term.

Monitoring and Adjustment

• Monitor serum calcium levels every 4-6 hours initially, adjusting the infusion rate to achieve a calcium level of 7-8 mg/dL.
• Once stable, transition to oral supplements only. This approach is necessary because severe hypocalcemia can lead to life-threatening complications such as seizures, laryngospasm, and cardiac arrhythmias, as noted in the study 1.

Considerations

• The study 1 highlights the importance of individualized treatment for hypocalcemia, particularly in patients with chronic kidney disease (CKD).
• The use of calcimimetics, such as cinacalcet, may increase the prevalence of hypocalcemia in patients with CKD, and the clinical implications of this increased incidence are uncertain 1.
• However, patients with significant or symptomatic hypocalcemia could still benefit from correction to prevent adverse consequences, as suggested in the study 1.

From the FDA Drug Label

Calcium Gluconate Injection is a form of calcium indicated for pediatric and adult patients for the treatment of acute symptomatic hypocalcemia. Individualize the dose within the recommended range in adults and pediatric patients depending on the severity of symptoms of hypocalcemia, the serum calcium level, and the acuity of onset of hypocalcemia. See Table 1 in the FPI for dosing recommendations in mg of calcium gluconate for neonates, pediatric and adult patients. Administer intravenously (bolus or continuous infusion) via a secure intravenous line

To correct hypocalcemia, calcium gluconate should be administered intravenously in a dose individualized based on the severity of symptoms, serum calcium level, and acuity of onset. The dose should be administered via a secure intravenous line and can be given as a bolus or continuous infusion. It is essential to monitor serum calcium levels every 4 to 6 hours during intermittent infusions and every 1 to 4 hours during continuous infusion. Dosing recommendations can be found in Table 1 of the full prescribing information 2.

From the Research

Correction of Hypocalcemia

To correct hypocalcemia, the following steps can be taken:

• Calcium replacement is the cornerstone of treatment, with elementary calcium replacement of 40 to 80 mg/kg/d recommended for asymptomatic newborns 3
• For acute treatment of hypocalcemia in patients with symptoms of tetany or hypocalcemic convulsion, elementary calcium of 10 to 20 mg/kg (1-2 mL/kg/dose 10% calcium gluconate) can be given as a slow intravenous infusion 3
• Oral calcium and/or vitamin D supplementation is commonly used to treat chronic hypocalcemia 4
• In cases of hypoparathyroidism, providing the missing hormone with recombinant human PTH(1-84) has been approved by the FDA and EMA, and can be effective in correcting serum calcium levels and reducing the need for calcium and active vitamin D supplements 4

Special Considerations

• In patients with chronic kidney disease, a new formula for approximating corrected calcium concentrations has been developed, which takes into account not only albumin but also pH and phosphate levels 5
• Patients with secondary osteoporosis associated with primary sclerosing cholangitis may be at risk of severe hypocalcemia when treated with denosumab, and should be closely monitored for serum calcium levels 6
• Patients with a history of subclinical hypoparathyroidism may be at risk of prolonged, symptomatic hypocalcemia when treated with pamidronate, and should be closely monitored for serum calcium levels 7

Treatment Approach

• The treatment approach for hypocalcemia should be individualized based on the underlying cause and severity of the condition 3, 4
• It is essential to investigate the etiology of hypocalcemia while initiating treatment, especially in infants with reduced calcium levels 3
• Close monitoring of serum calcium levels is crucial in patients with high risk factors for hypocalcemia, such as those with chronic kidney disease or secondary osteoporosis associated with primary sclerosing cholangitis 6, 5