What is the treatment for hypocalcemia (low calcium levels)?

Treatment of Hypocalcemia

The treatment for hypocalcemia depends on symptom severity, with symptomatic patients requiring immediate calcium supplementation through calcium gluconate 50-100 mg/kg IV administered slowly with ECG monitoring for acute cases, while oral calcium salts such as calcium carbonate combined with vitamin D sterols are appropriate for chronic management. 1, 2, 3

Assessment of Hypocalcemia

• Hypocalcemia is defined as serum calcium levels below 8.4 mg/dL (2.10 mmol/L) 1, 4
• Clinical symptoms include paresthesia, Chvostek's and Trousseau's signs, bronchospasm, laryngospasm, tetany, and seizures 1, 5
• Verify if hypocalcemia is true or due to hypoalbuminemia using the formula: Corrected total calcium (mg/dL) = Total calcium (mg/dL) + 0.8 [4 - Serum albumin (g/dL)] 4, 6
• Low ionized calcium levels at admission are associated with increased mortality and need for massive transfusion in trauma patients 1

Acute Symptomatic Hypocalcemia Management

• For symptomatic patients, administer calcium gluconate 50-100 mg/kg IV slowly with ECG monitoring 1
• Calcium chloride injection (10%) is indicated when prompt increase in plasma calcium levels is required 2
• Calcium gluconate injection is specifically indicated for acute symptomatic hypocalcemia in both pediatric and adult patients 3
• Monitor cardiac rhythm and ECG during IV calcium administration due to risk of cardiac complications 1, 7
• Use caution if phosphate levels are high, as increased calcium might increase the risk of calcium phosphate precipitation in tissues 1

Chronic Hypocalcemia Management

• For asymptomatic patients with mild hypocalcemia, no immediate intervention is recommended 1, 7
• Treatment is indicated when:
  • Clinical symptoms of hypocalcemia are present 1, 5
  • Plasma intact PTH level is above the target range for the CKD stage 1
• Oral calcium supplementation (calcium carbonate) should be used for long-term management 1
• Vitamin D supplementation should be added:
  • Check 25-hydroxyvitamin D levels if calcium is low 1, 4
  • If 25-hydroxyvitamin D is <30 ng/mL, initiate vitamin D2 (ergocalciferol) supplementation 1
  • For patients with CKD and persistent PTH elevation, active vitamin D sterols (calcitriol, alfacalcidol, or doxercalciferol) may be indicated 1

Special Considerations

• Total elemental calcium intake (dietary plus supplements) should not exceed 2,000 mg/day 1
• Monitor serum calcium and phosphorus levels every 3 months during treatment 1, 7
• Discontinue vitamin D therapy if serum corrected total calcium exceeds 10.2 mg/dL or if hyperphosphatemia persists 1
• For hypocalcemia in Williams syndrome, consider more frequent monitoring (every 4-6 months until 2 years of age, then every 2 years) 1
• Identify and address underlying causes of hypocalcemia, which may include:
  • Hypoparathyroidism (often postsurgical) 5, 7
  • Vitamin D deficiency 8, 7
  • Medication-induced hypocalcemia (bisphosphonates, cisplatin, antiepileptics, aminoglycosides, proton pump inhibitors) 9
  • Massive blood transfusion due to citrate binding calcium 1, 6

Monitoring During Treatment

• For acute management, monitor calcium levels frequently until stabilized 1, 7
• For chronic management, check serum calcium and phosphorus every 3 months 1, 4
• Reassess vitamin D levels annually in patients with chronic hypocalcemia 1, 4
• Monitor for hypercalciuria in patients on long-term calcium and vitamin D supplementation 1, 7