From the Guidelines
Hypercalcemia requires hospital admission when it is severe (calcium >14 mg/dL or >3.5 mmol/L), symptomatic, or when there are complications that cannot be managed as an outpatient. Patients with moderate hypercalcemia (calcium 12-14 mg/dL) who are experiencing significant symptoms such as altered mental status, severe dehydration, acute kidney injury, cardiac arrhythmias, or seizures should be admitted. Additionally, admission is necessary when the underlying cause requires immediate inpatient management, such as newly diagnosed malignancy with hypercalcemia of malignancy, as seen in multiple myeloma where development of hypercalcemia (corrected serum calcium > 11.5 mg/dL or 2.65 mmol/L) is a criterion for relapse 1. Initial management typically includes aggressive IV fluid rehydration with normal saline at 200-300 mL/hour (adjusted based on cardiac and renal status), followed by bisphosphonates such as zoledronic acid 4 mg IV or pamidronate 60-90 mg IV. Calcitonin 4 IU/kg SC every 12 hours may be added for rapid but short-term calcium reduction. Patients with mild, asymptomatic hypercalcemia (calcium <12 mg/dL) who can maintain adequate oral hydration and follow up reliably can often be managed as outpatients with close monitoring, considering guidelines for managing hypercalcemia in chronic kidney disease, where dialysis using low dialysate calcium may be used for persistent hypercalcemia despite modification of therapy 1. The urgency of admission is based on both the absolute calcium level and the rate of rise, as rapidly developing hypercalcemia is often more symptomatic than chronic elevations that develop gradually.
Key considerations for admission include:
- Severity of hypercalcemia
- Presence of symptoms
- Underlying cause and need for immediate inpatient management
- Ability to manage complications as an outpatient
- Rate of rise of calcium levels
- Overall clinical judgment based on patient-specific factors, prioritizing morbidity, mortality, and quality of life as outcomes.
From the Research
Hypercalcemia Admission Criteria
Hypercalcemia is a condition that affects approximately 1% of the worldwide population 2. The decision to admit a patient with hypercalcemia depends on the severity of the condition and the presence of symptoms.
- Mild hypercalcemia, defined as total calcium of less than 12 mg/dL (<3 mmol/L) or ionized calcium of 5.6 to 8.0 mg/dL (1.4-2 mmol/L), is usually asymptomatic and may not require admission 2.
- Severe hypercalcemia, defined as total calcium of 14 mg/dL or greater (>3.5 mmol/L) or ionized calcium of 10 mg/dL or greater (≥2.5 mmol/L), can cause nausea, vomiting, dehydration, confusion, somnolence, and coma, and typically requires admission 2, 3.
- Patients with symptomatic hypercalcemia, such as those with nausea, vomiting, dehydration, confusion, somnolence, and coma, should be admitted for treatment 3.
- The severity index criteria, including severe dehydration, mental status alteration, renal impairment, cardiac arrhythmias, ionized calcium level, nausea or vomiting, and low social level, should be considered at admission 3.
Treatment of Hypercalcemia
The treatment of hypercalcemia depends on the underlying cause and the severity of the condition.
- Initial therapy of symptomatic or severe hypercalcemia consists of hydration and intravenous bisphosphonates, such as zoledronic acid or pamidronate 2, 3.
- Glucocorticoids may be used as primary treatment when hypercalcemia is due to excessive intestinal calcium absorption (vitamin D intoxication, granulomatous disorders, some lymphomas) 2.
- In patients with kidney failure, denosumab and dialysis may be indicated 2.
- The use of bisphosphonates, such as pamidronate and zoledronic acid, is effective in reducing serum calcium levels, but may be associated with an increased risk of serum creatinine elevations in patients with preexisting renal dysfunction 4.
- The addition of calcitonin to bisphosphonate therapy may not provide substantial clinical benefit and increases cost 5.