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

From the Guidelines

To treat low calcium, increase your dietary calcium intake and consider supplements, but avoid excessive calcium loading, as it may be harmful in all GFR categories of CKD, as suggested by the 2017 clinical practice guideline update 1.

Treatment Approach

• Increase dietary calcium intake by consuming foods like dairy products, leafy greens, fortified foods, and calcium-rich nuts.
• If diet alone isn't sufficient, calcium supplements such as calcium carbonate (500-600 mg elemental calcium per tablet) or calcium citrate (200-300 mg per tablet) can be taken, typically 1-2 tablets 2-3 times daily with meals for better absorption.
• Vitamin D supplementation (800-1000 IU daily) is often necessary alongside calcium as it helps with calcium absorption.
• For severe deficiency, your doctor may prescribe prescription-strength supplements or medications.

Important Considerations

• Avoid excessive caffeine, alcohol, and sodium which can deplete calcium levels.
• Underlying causes like parathyroid disorders, vitamin D deficiency, or certain medications should be addressed.
• If you experience symptoms like muscle cramps, numbness, or tingling, seek medical attention as severe hypocalcemia can lead to serious complications including seizures and heart rhythm abnormalities.
• Regular blood tests may be needed to monitor calcium levels while undergoing treatment.

Guiding Principle

The treatment approach should prioritize avoiding hypercalcemia, as new evidence suggests that it may be harmful in all GFR categories of CKD 1.

Key Evidence

The 2017 clinical practice guideline update provides the most recent and highest quality evidence for the treatment of low calcium in patients with CKD, emphasizing the importance of avoiding excessive calcium loading and hypercalcemia 1.

From the FDA Drug Label

The optimal daily dose of calcitriol must be carefully determined for each patient. The effectiveness of calcitriol therapy is predicated on the assumption that each patient is receiving an adequate but not excessive daily intake of calcium. Patients are advised to have a dietary intake of calcium at a minimum of 600 mg daily. The U. S. RDA for calcium in adults is 800 mg to 1200 mg. To ensure that each patient receives an adequate daily intake of calcium, the physician should either prescribe a calcium supplement or instruct the patient in proper dietary measures.

Treatment for low calcium involves ensuring an adequate daily intake of calcium, with a minimum of 600 mg daily and a recommended daily intake of 800 mg to 1200 mg for adults.

• The physician may prescribe a calcium supplement or instruct the patient in proper dietary measures to achieve this goal.
• Calcitriol therapy may also be used, with careful determination of the optimal daily dose for each patient and monitoring of serum calcium levels 2.
• For acute, symptomatic hypocalcemia, Calcium Gluconate Injection may be used, with safety and effectiveness established in pediatric patients and dosing recommendations based on published literature and clinical experience 3.

From the Research

Treatment Options for Low Calcium

• Intravenous calcium infusion is essential to raise calcium levels and resolve or minimize symptoms in the setting of acute hypocalcemia 4
• Oral calcium and/or vitamin D supplementation is the most frequently used treatment for chronic hypocalcemia 4, 5
• In hypoparathyroidism, providing the missing hormone with the use of the recombinant human (rh) PTH(1-84) has been recently approved by the Food and Drug Administration (FDA) and the European Medicines Agency (EMA) 4
• Treatment can be further intensified with thiazide diuretics, phosphate binders, and a low-salt and low-phosphorus diet when treating hypocalcemia secondary to hypoparathyroidism 5

Calcium Supplementation

• Calcium from carbonate and citrate are the most common forms of calcium supplements 6
• Calcium carbonate, the most cost-effective form, should be taken with a meal to ensure optimal absorption 6
• Calcium citrate can be taken without food and is the supplement of choice for individuals with achlorhydria or who are taking histamine-2 blockers or protein-pump inhibitors 6
• The maximum dose of elemental calcium that should be taken at a time is 500 mg 6

Management of Hypocalcemia

• Management of chronic hypocalcemia requires knowledge of the factors that influence the complex regulatory axes of calcium homeostasis in a given disorder 7
• Family physicians play a crucial role in educating patients about the long-term management and complications of hypocalcemia 5
• Routine oral calcium and calcitriol supplementation in patients after thyroidectomy seems to be less expensive and results in higher patient utility than selective supplementation 8