From the Guidelines
Hypercalcemia is characterized by physical exam findings such as bone pain, abdominal tenderness, and neurological symptoms like confusion and altered mental status, which are crucial for early detection and management. The clinical manifestations of hypercalcemia can be remembered by the mnemonic "bones, stones, groans, and psychiatric overtones" 1. Patients may present with symptoms such as kidney stones, constipation, nausea, fatigue, and cardiac arrhythmias.
Clinical Manifestations
- Bone pain
- Abdominal tenderness
- Neurological symptoms like confusion and altered mental status
- Kidney stones
- Constipation
- Nausea
- Fatigue
- Cardiac arrhythmias
Management
The management of hypercalcemia begins with addressing the underlying cause, which can be primary hyperparathyroidism or malignancy, as seen in multiple myeloma 1. Initial treatment focuses on hydration with intravenous normal saline to promote calcium excretion, with careful monitoring for fluid overload. Loop diuretics like furosemide can be added after adequate hydration to enhance calcium excretion. For moderate to severe hypercalcemia, bisphosphonates such as zoledronic acid are effective in rapidly lowering calcium levels 1.
Treatment Options
- Hydration with intravenous normal saline
- Loop diuretics like furosemide
- Bisphosphonates such as zoledronic acid
- Calcitonin
- Denosumab
- Cinacalcet
- Glucocorticoids
The NCCN guidelines recommend zoledronic acid as the preferred bisphosphonate for the treatment of hypercalcemia in patients with multiple myeloma 1. Ongoing management includes monitoring calcium levels, maintaining hydration, limiting dietary calcium, and addressing the underlying condition. In severe cases, hemodialysis may be required. It is essential to note that the management of hypercalcemia should be individualized based on the underlying cause and the patient's clinical presentation.
From the FDA Drug Label
The FDA drug label does not answer the question.
From the Research
Clinical Manifestations of Hypercalcemia
- Hypercalcemia can be asymptomatic, especially in mild cases, but may be associated with constitutional symptoms such as fatigue and constipation in approximately 20% of people 2
- Severe hypercalcemia can cause nausea, vomiting, dehydration, confusion, somnolence, and coma 2
- Altered mental status and gait instability can also be presenting symptoms of hypercalcemia, as seen in a case of primary hyperparathyroidism 3
- The classic symptoms of hypercalcemia include "stones, bones, abdominal moans and psychic groans" 3
Physical Exam Findings
- Patients with hypercalcemia may exhibit signs of dehydration, such as dry mouth and decreased urine output 2
- Neurological deficits, such as altered mental status and gait instability, can be present in severe cases 3
- Abdominal symptoms, such as constipation and abdominal pain, can also be observed 2
Management of Hypercalcemia
- Mild hypercalcemia usually does not need acute intervention, but observation and monitoring may be necessary 2
- Initial therapy of symptomatic or severe hypercalcemia consists of hydration and intravenous bisphosphonates, such as zoledronic acid or pamidronate 2
- Glucocorticoids may be used as primary treatment when hypercalcemia is due to excessive intestinal calcium absorption (vitamin D intoxication, granulomatous disorders, some lymphomas) 2
- Parathyroidectomy may be considered in patients with primary hyperparathyroidism, depending on age, serum calcium level, and kidney or skeletal involvement 2