Hypocalcemia medical therapy: Difference between revisions
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== Overview == | |||
Cause, severity and the presence of [[symptoms]] guide the treatment of [[hypocalcemia]]. Mild to moderate cases of [[hypocalcemia]] can be treated by giving oral [[calcium]] and [[vitamin D]] supplements but in severe cases [[intravenous]] (IV) [[calcium gluconate]] is preferred. Most of the [[Hypocalcemia|hypocalcemic]] cases are mild and require only supportive treatment and laboratory evaluation. | |||
== | ==Medical Therapy== | ||
* Pharmacologic medical therapies for [[hypocalcemia]] include [[calcium]], [[vitamin D]] [[Calcium gluconate|, calcium gluconate]]<ref name="pmid18535072">{{cite journal |vauthors=Cooper MS, Gittoes NJ |title=Diagnosis and management of hypocalcaemia |journal=BMJ |volume=336 |issue=7656 |pages=1298–302 |date=June 2008 |pmid=18535072 |pmc=2413335 |doi=10.1136/bmj.39582.589433.BE |url=}}</ref><ref name="pmid231481472">{{cite journal |vauthors=Carroll R, Matfin G |title=Endocrine and metabolic emergencies: hypocalcaemia |journal=Ther Adv Endocrinol Metab |volume=1 |issue=1 |pages=29–33 |date=February 2010 |pmid=23148147 |pmc=3474611 |doi=10.1177/2042018810366494 |url=}}</ref><ref name="pmid185350722">{{cite journal |vauthors=Cooper MS, Gittoes NJ |title=Diagnosis and management of hypocalcaemia |journal=BMJ |volume=336 |issue=7656 |pages=1298–302 |date=June 2008 |pmid=18535072 |pmc=2413335 |doi=10.1136/bmj.39582.589433.BE |url=}}</ref> | |||
* Patients who present with [[asymptomatic]] hypocalcemia, it is important to repeat the levels of ionized [[calcium]] and confirm it. | |||
==== Therapeutic approach==== | |||
* Patients who present with hypocalcemia, [[intravenous]] (IV) [[calcium]] therapy is recomended, especially in patients who exhibit the following features<ref name="pmid23148147">{{cite journal |vauthors=Carroll R, Matfin G |title=Endocrine and metabolic emergencies: hypocalcaemia |journal=Ther Adv Endocrinol Metab |volume=1 |issue=1 |pages=29–33 |date=February 2010 |pmid=23148147 |pmc=3474611 |doi=10.1177/2042018810366494 |url=}}</ref> | |||
** Patients who have prolonged [[QT interval]]. | |||
** Patients who have [[serum]] corrected [[calcium]] of ≤7.5 mg/dL. | |||
** Patients who are positive for clinical symptoms such as [[carpopedal spasm]], [[tetany]], [[Seizure|seizures]]. | |||
* Patients who are presenting with milder [[symptoms]] of neuromuscular irritability like [[paresthesias]] and corrected calcium levels more than 7.5 mg/dL treating with oral calcium and vitamin D supplements is of first choice. | |||
* Patients with milder hypocalcemia who are on the oral supplements and shows no sign of improvement the next best best step in treating would be switching to IV calcium. | |||
* And patients who are requiring intravenous (IV) repletion should be admitted. | |||
** Preferred regimen (1): Elemental calcium 1-3 g/d. | |||
==== Severe Hypocalcemia ==== | |||
* IV calcium is recommended for patients who shows symptoms of severe hypocalcemia like the following<ref name="Dickerson2007">{{cite journal|last1=Dickerson|first1=Roland N.|title=Treatment of hypocalcemia in critical illness—part 1|journal=Nutrition|volume=23|issue=4|year=2007|pages=358–361|issn=08999007|doi=10.1016/j.nut.2007.01.011}}</ref><ref name="pmid171172922">{{cite journal |vauthors=Maeda SS, Fortes EM, Oliveira UM, Borba VC, Lazaretti-Castro M |title=Hypoparathyroidism and pseudohypoparathyroidism |journal=Arq Bras Endocrinol Metabol |volume=50 |issue=4 |pages=664–73 |date=August 2006 |pmid=17117292 |doi= |url=}}</ref> | |||
** Carpopedal spasm | |||
** Tetany | |||
** Seizures | |||
** QT interval prolongation | |||
* IV calcium is recommended for asymptomatic patients whose serum corrected calcium levels are ≤7.5 mg/dL. | |||
* If left untreated asymptomatic patients may end up with serious complications. | |||
* Following post-radical neck dissection patients may end up with acute hypoparathyroidism which leads to acute hypocalcemia due to rapid reduction in serum calcium<ref name="pmid23068088">{{cite journal |vauthors=Cayo AK, Yen TW, Misustin SM, Wall K, Wilson SD, Evans DB, Wang TS |title=Predicting the need for calcium and calcitriol supplementation after total thyroidectomy: results of a prospective, randomized study |journal=Surgery |volume=152 |issue=6 |pages=1059–67 |date=December 2012 |pmid=23068088 |pmc=4538326 |doi=10.1016/j.surg.2012.08.030 |url=}}</ref><ref name="pmid26456131">{{cite journal |vauthors=Raffaelli M, De Crea C, D'Amato G, Moscato U, Bellantone C, Carrozza C, Lombardi CP |title=Post-thyroidectomy hypocalcemia is related to parathyroid dysfunction even in patients with normal parathyroid hormone concentrations early after surgery |journal=Surgery |volume=159 |issue=1 |pages=78–84 |date=January 2016 |pmid=26456131 |doi=10.1016/j.surg.2015.07.038 |url=}}</ref> | |||
** Preferred regimen (1): IV calcium gluconate 1 or 2 g in 50 mL of 5 percent dextrose or normal saline given over 10 to 20 minutes. | |||
** Due to risk of serious cardiac dysfunction, calcium should be given slowly. | |||
* Following should be considered while preparing the IV calcium infusion | |||
** Calcium should be diluted in dextrose or water because concentrated calcium is an irritant to veins. | |||
** IV infusion should not contain bicarbonate or phosphate. | |||
* Until the patient receives oral calcium and vitamin D, IV calcium should be continued. | |||
== | ==== Mild or Chronic hypocalcemia ==== | ||
* | * When serum corrected calcium levels are between 7.5 to 8.0 mg/dL are considered as mild hypocalcemia.<ref name="pmid3213620">{{cite journal |vauthors=Harvey JA, Zobitz MM, Pak CY |title=Dose dependency of calcium absorption: a comparison of calcium carbonate and calcium citrate |journal=J. Bone Miner. Res. |volume=3 |issue=3 |pages=253–8 |date=June 1988 |pmid=3213620 |doi=10.1002/jbmr.5650030303 |url=}}</ref> | ||
* | * Oral calcium supplementation is preferred for the patients who are presenting with mild or chronic hypokalemia. | ||
** Preferred regimen (1): Elemental calcium( calcium carbonate or calcium citrate) 500 to 2000 mg in divided doses. | |||
===Contraindicated medications=== | ===Contraindicated medications === | ||
{{MedCondContrAbs | {{MedCondContrAbs | ||
Latest revision as of 12:25, 13 August 2018
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Vamsikrishna Gunnam M.B.B.S [2]
Overview
Cause, severity and the presence of symptoms guide the treatment of hypocalcemia. Mild to moderate cases of hypocalcemia can be treated by giving oral calcium and vitamin D supplements but in severe cases intravenous (IV) calcium gluconate is preferred. Most of the hypocalcemic cases are mild and require only supportive treatment and laboratory evaluation.
Medical Therapy
- Pharmacologic medical therapies for hypocalcemia include calcium, vitamin D , calcium gluconate[1][2][3]
- Patients who present with asymptomatic hypocalcemia, it is important to repeat the levels of ionized calcium and confirm it.
Therapeutic approach
- Patients who present with hypocalcemia, intravenous (IV) calcium therapy is recomended, especially in patients who exhibit the following features[4]
- Patients who have prolonged QT interval.
- Patients who have serum corrected calcium of ≤7.5 mg/dL.
- Patients who are positive for clinical symptoms such as carpopedal spasm, tetany, seizures.
- Patients who are presenting with milder symptoms of neuromuscular irritability like paresthesias and corrected calcium levels more than 7.5 mg/dL treating with oral calcium and vitamin D supplements is of first choice.
- Patients with milder hypocalcemia who are on the oral supplements and shows no sign of improvement the next best best step in treating would be switching to IV calcium.
- And patients who are requiring intravenous (IV) repletion should be admitted.
- Preferred regimen (1): Elemental calcium 1-3 g/d.
Severe Hypocalcemia
- IV calcium is recommended for patients who shows symptoms of severe hypocalcemia like the following[5][6]
- Carpopedal spasm
- Tetany
- Seizures
- QT interval prolongation
- IV calcium is recommended for asymptomatic patients whose serum corrected calcium levels are ≤7.5 mg/dL.
- If left untreated asymptomatic patients may end up with serious complications.
- Following post-radical neck dissection patients may end up with acute hypoparathyroidism which leads to acute hypocalcemia due to rapid reduction in serum calcium[7][8]
- Preferred regimen (1): IV calcium gluconate 1 or 2 g in 50 mL of 5 percent dextrose or normal saline given over 10 to 20 minutes.
- Due to risk of serious cardiac dysfunction, calcium should be given slowly.
- Following should be considered while preparing the IV calcium infusion
- Calcium should be diluted in dextrose or water because concentrated calcium is an irritant to veins.
- IV infusion should not contain bicarbonate or phosphate.
- Until the patient receives oral calcium and vitamin D, IV calcium should be continued.
Mild or Chronic hypocalcemia
- When serum corrected calcium levels are between 7.5 to 8.0 mg/dL are considered as mild hypocalcemia.[9]
- Oral calcium supplementation is preferred for the patients who are presenting with mild or chronic hypokalemia.
- Preferred regimen (1): Elemental calcium( calcium carbonate or calcium citrate) 500 to 2000 mg in divided doses.
Contraindicated medications
Hypocalcemia is considered an absolute contraindication to the use of the following medications:
References
- ↑ Cooper MS, Gittoes NJ (June 2008). "Diagnosis and management of hypocalcaemia". BMJ. 336 (7656): 1298–302. doi:10.1136/bmj.39582.589433.BE. PMC 2413335. PMID 18535072.
- ↑ Carroll R, Matfin G (February 2010). "Endocrine and metabolic emergencies: hypocalcaemia". Ther Adv Endocrinol Metab. 1 (1): 29–33. doi:10.1177/2042018810366494. PMC 3474611. PMID 23148147.
- ↑ Cooper MS, Gittoes NJ (June 2008). "Diagnosis and management of hypocalcaemia". BMJ. 336 (7656): 1298–302. doi:10.1136/bmj.39582.589433.BE. PMC 2413335. PMID 18535072.
- ↑ Carroll R, Matfin G (February 2010). "Endocrine and metabolic emergencies: hypocalcaemia". Ther Adv Endocrinol Metab. 1 (1): 29–33. doi:10.1177/2042018810366494. PMC 3474611. PMID 23148147.
- ↑ Dickerson, Roland N. (2007). "Treatment of hypocalcemia in critical illness—part 1". Nutrition. 23 (4): 358–361. doi:10.1016/j.nut.2007.01.011. ISSN 0899-9007.
- ↑ Maeda SS, Fortes EM, Oliveira UM, Borba VC, Lazaretti-Castro M (August 2006). "Hypoparathyroidism and pseudohypoparathyroidism". Arq Bras Endocrinol Metabol. 50 (4): 664–73. PMID 17117292.
- ↑ Cayo AK, Yen TW, Misustin SM, Wall K, Wilson SD, Evans DB, Wang TS (December 2012). "Predicting the need for calcium and calcitriol supplementation after total thyroidectomy: results of a prospective, randomized study". Surgery. 152 (6): 1059–67. doi:10.1016/j.surg.2012.08.030. PMC 4538326. PMID 23068088.
- ↑ Raffaelli M, De Crea C, D'Amato G, Moscato U, Bellantone C, Carrozza C, Lombardi CP (January 2016). "Post-thyroidectomy hypocalcemia is related to parathyroid dysfunction even in patients with normal parathyroid hormone concentrations early after surgery". Surgery. 159 (1): 78–84. doi:10.1016/j.surg.2015.07.038. PMID 26456131.
- ↑ Harvey JA, Zobitz MM, Pak CY (June 1988). "Dose dependency of calcium absorption: a comparison of calcium carbonate and calcium citrate". J. Bone Miner. Res. 3 (3): 253–8. doi:10.1002/jbmr.5650030303. PMID 3213620.