Teaching Points

• Symptoms of hypercalcemia include constipation, delayed reflexes, lethargy, confusion
• Etiologies for hypercalcemia (top 2) include:
  • Primary hyperparathyroidism
  • Malignancy
• Hypercalcemia secondary to malignancy can arise by different mechanisms:
  • PTHrP
    • Many of your solid tumors
    • Non-Hodgkin’s lymphoma
  • Bone Disease
    • Breast cancer
    • Multiple myeloma
  • Increased production of active Vitamin D
    • Hodgkin’s lymphoma
• Management of hypercalcemia of malignancy includes the following:
  • IV fluids for immediate effect
    • Many patients with high calcium levels are dehydrated.
    • This is due to hypercalcemia causing nephrogenic DI picture.
  • Calcitonin
    • Works within hours
    • Prone to tachyphylaxis
  • Bisphosphonates
    • Takes up to 48 hours before effect is seen
    • Pamidronate or Zolendronate
    • Caution in use for renal failure
  • Lasix
    • Only used in the setting of symptomatic hypervolemia.
• Diagnosis of Multiple Myeloma includes the following:
  • M-spike
  • Bone marrow biopsy with >10% plasma cells
  • Clinical manifestations based on the CRAB criteria:
    • HyperCalcemia – 25%
    • Renal dysfunction – 50%
    • Anemia – 75%
    • Bone involvement – 50%