What is the management of milk alkali syndrome?

Management of Milk-Alkali Syndrome

The management of milk-alkali syndrome requires immediate discontinuation of calcium and alkali supplements, aggressive intravenous hydration, and supportive care to correct hypercalcemia, metabolic alkalosis, and renal impairment.

Pathophysiology and Clinical Presentation

Milk-alkali syndrome (MAS) is characterized by the triad of:

• Hypercalcemia
• Metabolic alkalosis
• Renal impairment

This syndrome occurs due to excessive intake of calcium and absorbable alkali, particularly calcium carbonate. While historically associated with milk and sodium bicarbonate treatment for peptic ulcer disease, modern cases are more commonly related to calcium supplement use for osteoporosis prevention or antacid therapy 1.

Acute Management Algorithm

1. Immediate Interventions

• Discontinue all sources of calcium and alkali
  • Stop calcium supplements, calcium-containing antacids, and vitamin D preparations
  • Review all over-the-counter medications for hidden calcium/alkali content

2. Fluid Resuscitation

• Administer aggressive intravenous hydration
  • Normal saline (0.9% NaCl) at 2-3 L/m²/day 2
  • Target urine output of 80-100 mL/m²/hr
  • Monitor fluid balance carefully to avoid volume overload

3. Promote Calcium Excretion

• Consider loop diuretics after adequate volume repletion
  • Helps increase renal calcium excretion
  • Monitor electrolytes closely during diuretic therapy

4. Monitor and Correct Electrolyte Abnormalities

• Check serum calcium, phosphate, bicarbonate, and renal function every 4-6 hours initially
• Avoid potassium, calcium, and phosphate in initial IV fluids 2

5. Severe Cases

• Consider hemodialysis for:
  • Severe renal failure
  • Persistent severe hypercalcemia unresponsive to hydration
  • Severe neurological symptoms
  • Life-threatening cardiac arrhythmias

Special Considerations

Diagnostic Workup

• Measure parathyroid hormone (PTH) levels (typically suppressed in MAS)
• Check 1,25-dihydroxycholecalciferol levels (usually low in MAS)
• These help differentiate MAS from primary hyperparathyroidism 3

Monitoring Parameters

• Serum calcium and ionized calcium
• Renal function (BUN, creatinine)
• Acid-base status (pH, bicarbonate)
• Electrocardiogram for cardiac effects of hypercalcemia

Prevention of Recurrence

• Patient education about calcium and alkali content in medications and supplements
• Use alternative treatments for acid-related disorders (H2 blockers, proton pump inhibitors)
• For patients requiring calcium supplementation:
  • Use the lowest effective dose
  • Consider calcium citrate instead of calcium carbonate when appropriate
  • Regular monitoring of serum calcium and renal function
  • Avoid concomitant use of medications that can worsen renal function or cause alkalosis

Risk Factors for MAS Development

• Medications affecting glomerular filtration rate:
  • Angiotensin receptor blockers
  • Aldosterone receptor antagonists
  • Thiazide diuretics 4
• Dehydration
• Alkaline diet (e.g., vegetarian diet)
• Pregnancy
• Inadequate monitoring during calcium supplementation

Prognosis

With prompt recognition and appropriate treatment, milk-alkali syndrome is typically reversible. However, severe cases may require dialysis support temporarily 3. Long-term renal damage is possible in chronic cases with delayed diagnosis.