Hypercalcaemia ⬆️
Acute hypercalcaemia: severity thresholds, IV saline, bisphosphonates, and when to escalate. Based on Society for Endocrinology emergency guidance.
Hypercalcaemia assistant
Society for Endocrinology emergency guidance. Confirm local protocol.
Use albumin-adjusted Ca²⁺. Urgency bands follow Society for Endocrinology (<3.0 / 3.0–3.5 / >3.5). Bisphosphonate detail is guidance only.
Clinical factors
🚨 Red Flags / Escalation
- Adjusted Ca²⁺ >3.5 mmol/L: urgent correction. Risk of dysrhythmia and coma (Society for Endocrinology emergency guidance).
- Severe neurological features (confusion, coma), ECG changes (short QT), pancreatitis, or oliguric AKI → senior / ED review immediately.
- Raised PTH with severe hypercalcaemia poorly responsive to medical therapy → urgent endocrine / surgical review for parathyroidectomy.
- Always use albumin-adjusted (or ionised) calcium; confirm local lab reference ranges.
🧠 Severity (adjusted Ca²⁺)
- <3.0 mmol/L: often asymptomatic; usually does not need urgent correction.
- 3.0–3.5 mmol/L: may be tolerated if rise was slow, but treat promptly if symptomatic.
- >3.5 mmol/L: requires urgent correction (dysrhythmia / coma risk).
- Assistant chips: ≤2.6 not high; >2.6–<3.0 mild; 3.0–3.5 moderate; >3.5 severe.
🧾 Causes
- ~90% due to primary hyperparathyroidism or malignancy.
- High Ca²⁺ + high/inappropriately normal PTH → primary or tertiary hyperparathyroidism (consider FHH if mild and family history).
- High Ca²⁺ + low/suppressed PTH → malignancy or other non-PTH causes.
- Less common: thiazides, lithium, vitamin D excess, granulomatous disease (sarcoid/TB), thyrotoxicosis, immobilisation, milk-alkali, adrenal insufficiency, rhabdomyolysis, theophylline, phaeochromocytoma.
🩺 Clinical features
- Polyuria, thirst, anorexia, nausea, constipation.
- Mood change, cognitive dysfunction, confusion, coma.
- Renal impairment; nephrolithiasis / nephrocalcinosis.
- Muscle weakness; peptic ulceration; pancreatitis.
- ECG: shortened QT; hypertension / cardiomyopathy in severe disease.
🔍 Assessment
- History: symptom duration; weight loss, night sweats, cough; family history; drugs and OTC supplements (calcium, vitamin D, thiazides, lithium).
- Exam: cognition, fluid status; look for malignancy (nodes, breasts, abdomen, respiratory).
- ECG for short QT / conduction abnormality.
- Bloods: adjusted Ca²⁺, phosphate, PTH, U&Es; add ALP, Mg²⁺, vitamin D as indicated.
💧 First-line: rehydration
- IV 0.9% saline 4–6 L in 24 h (Society for Endocrinology). Adjust to clinical status; e.g. 3–6 L/24 h with K⁺/Mg²⁺ replacement as labs dictate.
- Monitor for fluid overload (elderly, heart failure, renal impairment); consider CVP / senior input if unsure.
- Loop diuretics are rarely used and only if fluid overload develops. They are not effective for lowering serum calcium (SfE). Avoid ECF depletion.
- Stop thiazides and other calcium-raising drugs; avoid immobilisation; maintain oral salt and water if able.
- Severe renal failure: consider dialysis against low-calcium dialysate.
💊 Bisphosphonates (if further treatment needed after saline)
- SfE: consider IV bisphosphonate if further treatment is required after IV saline.
- Zoledronic acid 4 mg IV over 15 min.
- OR pamidronate 30–90 mg (severity-dependent) at 20 mg/h.
- OR ibandronic acid 2–4 mg.
- Give more slowly and consider dose reduction in renal impairment; check local pharmacy monograph.
- Nadir typically at 2–4 days. Can cause hypocalcaemia if vitamin D deficient or PTH suppressed.
- Seek senior / endocrine / pharmacy advice before dosing in significant CKD.
🔁 Second-line / specialist
- Glucocorticoids (e.g. prednisolone 40 mg daily): lymphoma, granulomatous disease, or vitamin D toxicity. Usually effective in 2–4 days.
- Calcimimetics, denosumab, calcitonin: specialist supervision only; consider if poor response to first-line measures. Calcitonin alone has a modest, short-lived effect.
- Urgent parathyroidectomy: selected acute primary hyperparathyroidism with severe hypercalcaemia and poor medical response.
Based on
Note Template
Ready-to-use clinical note structure
🕒 08 / 10 / 2026 — 16:03 ATRP re: hypercalcaemia Patient: [age] [sex] Admission Dx: [reason for admission] PMHx: [malignancy / known hyperparathyroidism / CKD / granulomatous disease] 🧾 Hx: • Polyuria, thirst, nausea, constipation, confusion • Duration of symptoms / known calcium trend • Drugs: thiazides, lithium, calcium / vitamin D supplements • Red flags for malignancy: weight loss, night sweats, cough 🩺 Exam: • Vitals: HR __ BP __ RR __ Temp __ SpO₂ __ • Fluid status; cognition • Exam for underlying cause (nodes, breasts, abdomen, chest) • ECG: QT / conduction 📋 Impression: Adjusted Ca²⁺: __ mmol/L (mild / moderate / severe) Likely PTH pattern: [high or inappropriately normal vs suppressed] (PTH pending) Likely cause: [primary HPT / malignancy / drugs / other] 📌 Plan: • Stop thiazides / calcium-raising agents • IV 0.9% saline rehydration (target ~4–6 L/24 h if tolerated); monitor overload • Recheck U&Es, K⁺, Mg²⁺, adjusted Ca²⁺ • Bisphosphonate if indicated after rehydration (pharmacy / senior advice in CKD) • Endocrine / oncology / senior review as appropriate 👤 [Your Name], [Role] IMC: _______
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