How to correct hypocalcemia?

Management of Hypocalcemia: Guidelines for Correction

The treatment of hypocalcemia should be based on the severity of symptoms, calcium levels, and underlying cause, with symptomatic hypocalcemia requiring immediate IV calcium gluconate administration at 100-200 mg over 10-20 minutes, while chronic asymptomatic hypocalcemia can be managed with oral calcium supplementation and vitamin D. 1, 2

Acute Symptomatic Hypocalcemia

Immediate Management

• Intravenous calcium administration is required for symptomatic hypocalcemia (paresthesia, tetany, seizures, laryngospasm, bronchospasm) 3, 1
• Calcium gluconate is preferred over calcium chloride due to less tissue irritation 2
  • Dosage: 100-200 mg IV calcium gluconate (10-20 mL of 10% solution) administered slowly over 10-20 minutes
  • Do not exceed administration rate of 1 mL/min 2
  • Monitor ECG during administration, especially with concurrent cardiac glycoside use 1, 2

Administration Considerations

• Administer via secure IV line to avoid extravasation 2
• Use central or deep vein when possible 4
• Warm solution to body temperature if time permits 4
• Halt injection if patient reports discomfort; resume when symptoms disappear 4
• Patient should remain recumbent for a short time after injection 4

Monitoring During IV Calcium Administration

• Monitor serum calcium during intermittent infusions every 4-6 hours 2
• For continuous infusion, monitor every 1-4 hours 2
• Monitor ECG for cardiac arrhythmias, especially with concurrent cardiac glycoside use 1, 2

Chronic Hypocalcemia Management

Oral Calcium Supplementation

• Calcium carbonate is the preferred oral calcium salt (contains 40% elemental calcium) 1
• Total elemental calcium intake (dietary + supplements) should not exceed 2,000 mg/day 3, 1
• Typical dosage: 1,000-2,000 mg elemental calcium daily in divided doses 1

Vitamin D Therapy

• Add vitamin D supplementation to enhance calcium absorption 3, 1
  • Cholecalciferol (Vitamin D3): 800-1,000 IU daily 1
  • For vitamin D deficiency: Consider ergocalciferol (Vitamin D2) supplementation 3, 1
  • Target serum 25-hydroxyvitamin D level: >30 ng/mL 1

For CKD Patients

• CKD Stages 3-4: Maintain serum calcium within normal range for laboratory used 3
• CKD Stage 5: Maintain serum calcium within normal range, preferably toward lower end (8.4-9.5 mg/dL) 3
• For hypocalcemia in CKD patients:
  • Treat if symptomatic OR if plasma intact PTH is above target range for CKD stage 3
  • Use calcium salts (e.g., calcium carbonate) and/or oral vitamin D sterols 3
  • For vitamin D deficiency (<30 ng/mL): Initiate ergocalciferol therapy 3
  • Monitor serum calcium and phosphorus at least every 3 months 3

Special Considerations

Drug Interactions and Contraindications

• Separate calcium supplements from levothyroxine by at least 4 hours 1
• Avoid concurrent use with ceftriaxone (risk of precipitates, contraindicated in neonates) 1, 2
• Use caution with cardiac glycosides (increased risk of arrhythmias) 1, 2
• Calcium is not physically compatible with fluids containing phosphate or bicarbonate 2
• Calcium may reduce response to calcium channel blockers 2

Monitoring

• Regular monitoring of serum calcium, phosphorus, and magnesium levels 1
• Assess urine calcium/creatinine ratio to evaluate for hypercalciuria 1
• Monitor every 3-6 months until stable, then annually 1

Complications to Watch For

• Hypercalcemia from overcorrection 1
• Renal calculi formation 1
• Tissue necrosis with extravasation of IV calcium 1, 2
• Calcinosis cutis 1
• Calcium-phosphorus product >55 mg²/dL² in CKD patients (maintain <55) 3

Pediatric Dosing

• Calcium gluconate: Individualize dose based on severity of symptoms 2
• Calcium chloride: 2.7-5.0 mg/kg (0.027-0.05 mL/kg of 10% solution) 4
• May repeat dosing every 4-6 hours as needed 4

Elderly and Renal Impairment

• Start at lower end of dosage range 2
• Monitor serum calcium levels more frequently (every 4 hours) 2

By following these guidelines and adjusting treatment based on patient response and calcium levels, hypocalcemia can be effectively managed while minimizing potential complications.