Patient handout

Hypercalcemia evaluation

PRODUCTION

1. Your condition

This handout is for hypercalcemia evaluation. Your care team identified this based on: severe hypercalcemia — ca >14 mg/dl + altered mental status + ecg changes (short qt, t-wave changes, af, bradyarrhythmia) — stat iv ns (200-300 ml/h) + calcitonin 4 iu/kg sc/im q12h + bisphosphonate (zoledronate 4 mg iv or pamidronate 60-90 mg iv) or denosumab 60-120 mg sc if aki; hemodialysis if severe refractory + aki.

Other reasons your team may use this plan: moderate hypercalcemia — ca 12-14 mg/dl + symptoms (nausea, polyuria, confusion, weakness, constipation, bone pain) — ivf ns + bisphosphonate (zoledronate 4 mg iv) ± calcitonin if rapid normalization needed; workup cause; mild hypercalcemia — ca <12 mg/dl + asymptomatic — outpatient workup; pth first (pth-dependent vs independent); crab criteria screen for myeloma; thiazide / lithium review; hypercalcemia + elevated pth + low/normal urinary ca:cr ratio + osteoporosis — primary hyperparathyroidism (most common ambulatory cause, ~80%); route endo.hyperparathyroidism.v1; sestamibi scan + parathyroidectomy criteria (ca >1 above uln, egfr <60, t-score <-2.5, age <50, kidney stones).

3. When to call your provider

Contact your care team if any of the following happen:

Ca >14 or symptomatic (AMS, severe weakness, ECG changes) → ED for IVF + calcitonin + bisphosphonate
Acute AKI on outpatient labs → ED
New severe bone pain or pathologic fracture → emergent imaging + oncology
New altered mental status → ED
Severe arrhythmia → ED + cardiac workup
New diagnosis of malignancy → oncology STAT
Refractory hyperPTH despite cinacalcet → endocrine surgery referral
Suspected parathyroid carcinoma → emergent endocrine surgery referral

4. When to seek emergency care

Call 911 or go to the nearest emergency room right away if you have:

Severe hypercalcemia — Ca >14 mg/dL OR symptomatic (AMS, severe weakness, ECG changes, AKI) regardless of level — EMERGENT IVF NS + calcitonin + bisphosphonate; consider denosumab or HD if refractory (AACE PMID 28079225 — verify)(life-threatening)
Hypercalcemia + suppressed PTH + cancer history OR weight loss + B-symptoms + bone pain — malignancy hyperCa; PTHrP humoral (squamous, RCC, breast, ovarian — PMID 26261118 verify), lytic mets, lymphoma 1,25-D; route oncology + cancer screen
Hypercalcemia + CRAB features (renal failure, anemia, bone lesions) + monoclonal protein + age ≥50 — multiple myeloma; route heme.multiple-myeloma.chronic.v1; SPEP / UPEP / sFLC + skeletal survey + bone marrow biopsy
Hypercalcemia + suppressed PTH + elevated 1,25-(OH)2-D + chronic cough + hilar adenopathy + endemic exposure — granulomatous (sarcoid, TB, histoplasmosis, GPA — PMID 21527617 verify); HRCT + biopsy; corticosteroids
Hypercalcemia + episodic HTN + diaphoresis + palpitations + elevated metanephrines — pheochromocytoma (MEN-2 syndrome — co-occurs medullary thyroid + pheo); route endo.pheochromocytoma.v1; α-block before β-block before surgery

5. Follow-up

Cause-specific follow-up: parathyroidectomy 6 wk + 6 mo (Ca + PTH); cinacalcet (Ca + PTH + electrolytes q3 mo); cancer surveillance; granulomatous (treat underlying); deprescribing review; lifestyle (hydration, AVOID Ca / vit D supplements unless replacement specifically needed)

6. Sources

Guideline: AACE hypercalcemia 2017 (PMID 28079225 — verify) + NEJM Hypercalcemia 2017 (PMID 28680000 — verify) + PTHrP malignancy hypercalcemia (PMID 26261118 — verify) + denosumab refractory (PMID 30231007 — verify) + sarcoid hypercalcemia (PMID 21527617 — verify) + paraneoplastic (PMID 28110218)