Treatment of hypocalcemia
- David Goltzman, MD
David Goltzman, MD
- Professor of Medicine
- McGill University
- Senior Physician, Division of Endocrinology and Department of Medicine
- McGill University Health Centre
Hypocalcemia may be associated with a spectrum of clinical manifestations, ranging from few (if any) symptoms if the hypocalcemia is mild and/or chronic, to severe life-threatening symptoms if it is severe and/or acute. Thus, the management of hypocalcemia depends upon the severity of symptoms. In patients with acute symptomatic hypocalcemia, intravenous (IV) calcium gluconate is the preferred therapy, whereas chronic hypocalcemia is treated with oral calcium and vitamin D supplements.
The treatment of hypocalcemia will be reviewed here. The etiology, clinical manifestations, and diagnostic approach to hypocalcemia are reviewed separately. (See "Etiology of hypocalcemia in adults" and "Clinical manifestations of hypocalcemia" and "Diagnostic approach to hypocalcemia" and "Hypoparathyroidism".)
INTERPRETATION OF SERUM CALCIUM
Calcium in serum is bound to proteins, principally albumin. As a result, total serum calcium concentrations in patients with low or high serum albumin levels may not accurately reflect the physiologically important ionized (or free) calcium concentration. As an example, in patients with hypoalbuminemia (as may occur in patients with acute or chronic illness, volume overload, or malnutrition), total serum calcium concentration may be low when serum ionized calcium is normal. This phenomenon is called pseudohypocalcemia. The serum total calcium concentration falls approximately 0.8 mg/dL for every 1 g/dL reduction in the serum albumin concentration. Thus, in patients with hypoalbuminemia or hyperalbuminemia, the measured serum calcium concentration should be corrected for the abnormality in albumin (calculator 1) or for standard units (calculator 2). Patients with normal corrected serum calcium concentrations do not have true hypocalcemia and, therefore, do not require treatment for hypocalcemia. (See "Etiology of hypocalcemia in adults", section on 'Hypoalbuminemia'.)
If there is uncertainty whether the corrected serum calcium is reflective of the ionized calcium and if a laboratory known to measure ionized calcium reliably is available, it is preferable to measure the ionized calcium directly. Direct measurement of the ionized calcium concentration can also be measured in patients with symptoms of hypocalcemia in the setting of a normal total calcium concentration. Symptomatic hypocalcemia with normal total calcium, but low ionized calcium can occasionally occur in patients with acute respiratory alkalosis due to increased binding of calcium to albumin. (See "Relation between total and ionized serum calcium concentrations", section on 'Acid-base disorders'.)
In patients with asymptomatic hypocalcemia, it is important to verify with repeat measurement of ionized calcium or total serum calcium corrected for albumin that there is a true decrease in the calcium concentration.
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- INTERPRETATION OF SERUM CALCIUM
- THERAPEUTIC APPROACH
- Severe acute and/or symptomatic hypocalcemia
- - Intravenous calcium
- - Concurrent hypomagnesemia
- Mildly symptomatic or chronic hypocalcemia
- DISEASE-SPECIFIC APPROACH
- Vitamin D deficiency
- Chronic kidney disease
- Chronic liver disease
- Autosomal dominant hypocalcemia
- Hypercatabolic state
- INFORMATION FOR PATIENTS
- SUMMARY AND RECOMMENDATIONS