How to treat hypocalcemia?

Treatment of Hypocalcemia

For severe or symptomatic hypocalcemia (ionized calcium <0.8 mmol/L), administer intravenous calcium immediately, preferably calcium chloride over calcium gluconate in emergency situations. 1, 2, 3

Acute Management of Severe/Symptomatic Hypocalcemia

Immediate IV Calcium Administration

• Calcium chloride is the preferred agent in emergencies and in patients with liver dysfunction 1, 2
• 10 mL of 10% calcium chloride contains 270 mg of elemental calcium, compared to only 90 mg in the same volume of 10% calcium gluconate 1, 2
• This makes calcium chloride three times more potent for rapid correction 1
• Both agents are FDA-approved for acute symptomatic hypocalcemia 4, 3

Critical Monitoring During IV Administration

• Continuous ECG monitoring is essential during rapid calcium administration to detect cardiac dysrhythmias 1, 2
• Monitor ionized calcium levels frequently, especially during massive transfusion 1
• Check phosphate levels concurrently to avoid calcium phosphate precipitation 1, 2
• Never administer calcium and sodium bicarbonate through the same IV line due to precipitation risk 1, 2

Special Scenario: Massive Transfusion

• Continuous IV calcium infusion is required during massive transfusion due to citrate-mediated calcium chelation 1, 2
• Each unit of packed red blood cells or fresh frozen plasma contains approximately 3g of citrate that binds calcium 1, 2
• In trauma patients, hypocalcemia is associated with platelet dysfunction, decreased clot strength, increased transfusion requirements, and higher mortality 1, 2

Chronic Hypocalcemia Management

General Approach

• Use an individualized strategy rather than routine correction of all hypocalcemia 5, 1
• Significant or symptomatic hypocalcemia should be corrected to prevent adverse consequences including fatigue, irritability, seizures, cardiac arrhythmias (QT prolongation), and osteoporosis 5, 1
• Mild asymptomatic hypocalcemia does not universally require correction 5, 1, 2

Oral Supplementation

• Daily calcium and vitamin D supplementation are recommended for patients with chronic hypocalcemia 5
• For hypoparathyroidism, calcium and vitamin D must be carefully titrated to keep serum calcium in the low-normal range to minimize hypercalciuria and prevent renal dysfunction 6
• Magnesium supplementation is indicated for those with concurrent hypomagnesemia 5
• Hormonally active vitamin D metabolites (calcitriol) may be needed for severe cases, typically requiring endocrinology consultation 5

Chronic Kidney Disease Patients

• For dialysis patients, maintain dialysate calcium concentration between 1.25 and 1.50 mmol/L (2.5 and 3.0 mEq/L) 5, 1
• In CKD patients on calcimimetics (cinacalcet), mild to moderate hypocalcemia may not require aggressive correction, as the EVOLVE trial showed no adverse associations with persistently low calcium levels 5
• However, significant or symptomatic hypocalcemia still warrants correction 5

22q11.2 Deletion Syndrome

• 80% of adults with this syndrome have a lifetime history of hypocalcemia, typically due to hypoparathyroidism 5
• Daily calcium and vitamin D supplementation are recommended for all adults with this condition 5
• Targeted monitoring is critical during vulnerable periods: peri-operatively, perinatally, or during severe illness 5
• Avoid over-correction, which can cause iatrogenic hypercalcemia, renal calculi, and renal failure 5

Common Pitfalls to Avoid

• Verify true hypocalcemia by checking ionized calcium, as many cases are artifacts of hypoalbuminemia 7
• Be aware that hypocalcemia can be drug-induced by bisphosphonates, cisplatin, antiepileptics, aminoglycosides, and proton pump inhibitors 8
• Alcohol and carbonated beverages (colas) can worsen hypocalcemia 5
• In patients improving from psychiatric illness, treatment compliance with calcitriol may inadvertently improve, leading to over-correction 5