↑Ca; stones, bones, groans, psychiatric moans
Calculators: cca
Order: Ca, PTH, phosphate → ↑Ca, ↑/inappropriately normal PTH, ↓phosphate
Acute severe ↑Ca: NS 200–300 mL/h + Calcitonin 4 U/kg + Zoledronic acid / pamidronate IV; denosumab 60–120 mg SC if bisphosphonate contraindicated (CKD)
Definitive → Parathyroidectomy (localize with sestamibi)
Order set Ca, PTH, PO₄ Vitamin D U&E, 24-h urine Ca DEXA, renal imaging Criteria Admit Symptomatic/severe hypercalcaemia
ICU Ca >14 with arrhythmia/↓GCS
Discharge Ca controlled, surgical referral
Never Give thiazides (raise calcium further) Clinical detail — differentials, red flags, pitfalls, disposition Red flags Ca >14, confusion, arrhythmia Differentials Malignancy hypercalcaemia FHH Vitamin D toxicity Common mistakes Thiazides Missing malignancy as cause of ↑Ca Disposition & follow-up Acute ↑Ca → fluids/bisphosphonate; definitive parathyroidectomy.
Discharge package Medications Hydration; avoid thiazides
Follow-up Endocrine/surgery; monitor Ca
Lifestyle Adequate hydration
Warning symptoms Confusion, severe thirst, stones, bone pain
💊 Treatment detail — doses & preparation 0.9% Sodium chloride crystalloid
Dose Bolus 500 mL over 15–30 min, reassess; maintenance 1–1.5 mL/kg/h
Preparation 500/1000 mL bags; add KCl only after urine output confirmed
Monitor Hyperchloraemic acidosis with large volumes — prefer balanced (LR) for resuscitation
Calcitonin hypocalcaemic agent
Dose 4 IU/kg SC/IM q12h (hypercalcaemia) — onset 2–4 h
Preparation 100 IU/mL ampoule SC/IM
Monitor Ca²⁺ q12 h; tachyphylaxis after 48 h — bridge to bisphosphonate
Zoledronic acid IV bisphosphonate
Dose 4 mg IV over ≥15 min (hypercalcaemia, myeloma bone); renal dose-adjust (3–3.5 mg if CrCl 30–60)
Preparation 4 mg/5 mL ready solution or vial dilute in 100 mL NS
Monitor Ca²⁺, creatinine; hypocalcaemia/hypophosphataemia after; dental review (ONJ)
Cinacalcet calcimimetic
Dose 30 mg BD titrated (parathyroid carcinoma/dialysis patients)
Preparation 30/60/90 mg tablets with food
Monitor Ca²⁺, nausea; hypocalcaemia
📖 AACE / Endocrine Society Reviewed July 2026