1. Hypercalcemia A diagnostic and treatment approach UCI Internal Medicine – Mini Lecture

2. Objectives Understand the most common etiologies Have a clear diagnostic plan Understand acute management

3. Initial evaluation A 68 year-old female with no PMH or home meds is brought to the ER by family with altered mental status, nausea, and diffuse bony pain.

4. Initial Evaluation VS unremarkable. A&Ox1, tries to get out of bed and is distracted. Rest of exam is normal. 12 290 12 39 Diff wnl 139 3.8201 11112 104 13 1.4 1.8 7.3 40.4 10622 21 Corrected Calcium = (0.8 * (Normal Albumin - Pt's Albumin)) + Serum Ca

5. Calcium reminders: Absorbed through small intestine via a vitamin-D dependent pump Excreted by the kidney PTH: production of active Vitamin D, renal reabsorption and osteoclast activity

6. Diagnostic Approach PTH-mediated? PTHrp? Excess vitamin D? Something else? (eg: genetic, MM)

7. Diagnostic Approach ✓ PTH ↑ Likely 1° ↑ PTH Poss. FHH ✓ urine Ca ↑ (>200mg/day)1° ↑ PTH ↓ (<100mg/day)FHH ↓ Non-PTH mediated ✓ PTHrp & Vitamin D ↑ PTHrpLook for cancer ↑ 1,25D CXR (Lymphoma, Granulomatous disease) Normal D and PTHrp SPEP, UPEP, TSH ↑ 25DRecheck meds

8. Treatment Mild (<12): No acute tx necessary – Avoid thiazides and lithium, volume depletion – Low calcium diet Moderate (12-14): May or may not require tx

9. Severe Hypercalcemia (>14) Normal Saline (UTD recommends 200cc/hr, adjust for UOP 100-150cc/hr) – With Lasix as necessary Calcitonin 4 IU/kg Q12 hrs (if Ca>14) Cancer: Bisphosphonates (Reclast 4mg IV over 15 mins) Dialysis if these fail Monitor with Q8 serum calcium levels

10. Treat Underlying Cause Multiple Myeloma Squamous Cell Cancer Gynecologic Cancer Sarcoidosis Tuberculosis Thyrotoxicosis Pituitary Adenoma Multiple Endocrine Neoplasia

11. The case Admitted to medicine for IVF PTH 77 (normal 11-55); Urinary calcium 425mg/day Tc99m-sestamibi demonstrated a single parathyroid adenoma Referred to surgery for parathyroidectomy

12. Take home points Hypercalcemia can present asymptomatically or with very vague symptoms (stones, bones, groans…) Still worth treating (risk for nephrolithiasis, arrhythmias, vascular calcification)

13. Take home points 1° hyperparathyroidism and malignancy are the most common causes Check PTH first. If not elevated, check vitamin D (both 25-OH and 1,25-OH) Treat all symptomatic patients with IVF