Official reprint from UpToDate®
www.uptodate.com ©2015 UpToDate®

Treatment of hypocalcemia

David Goltzman, MD
Section Editor
Clifford J Rosen, MD
Deputy Editor
Jean E Mulder, MD


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 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".)


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, total serum calcium concentration may be low when serum ionized calcium is normal. 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).

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, some authorities prefer to measure the ionized calcium directly. Direct measurement of the ionized calcium concentration could be considered 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 (ionized calcium or total serum calcium corrected for albumin) that there is a true decrease in the calcium concentration.


Subscribers log in here

To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information or to purchase a personal subscription, click below on the option that best describes you:
Literature review current through: Feb 2015. | This topic last updated: May 8, 2014.
The content on the UpToDate website is not intended nor recommended as a substitute for medical advice, diagnosis, or treatment. Always seek the advice of your own physician or other qualified health care professional regarding any medical questions or conditions. The use of this website is governed by the UpToDate Terms of Use ©2015 UpToDate, Inc.
  1. Thakker R. Hypocalcemia: pathogenesis, differential diagnosis, and management. In Primer on the Metabolic Bone Diseases and Disorders of Mineral Metabolism, American Society of Bone and Mineral Research 2006; 6:213.
  2. Cooper MS, Gittoes NJ. Diagnosis and management of hypocalcaemia. BMJ 2008; 336:1298.
  3. Schilling T, Ziegler R. Current therapy of hypoparathyroidism--a survey of German endocrinology centers. Exp Clin Endocrinol Diabetes 1997; 105:237.
  4. Tohme JF, Bilezikian JP. Diagnosis and treatment of hypocalcemic emergencies. The Endocrinologist 1996; 6:10.
  5. Kanis JA, Russell RG. Rate of reversal of hypercalcaemia and hypercalciuria induced by vitamin D and its 1alpha-hydroxylated derivatives. Br Med J 1977; 1:78.
  6. Bell NH, Stern PH. Hypercalcemia and increases in serum hormone value during prolonged administration of 1alpha,25-dihydroxyvitamin D. N Engl J Med 1978; 298:1241.
  7. Halabe A, Arie R, Mimran D, et al. Hypoparathyroidism--a long-term follow-up experience with 1 alpha-vitamin D3 therapy. Clin Endocrinol (Oxf) 1994; 40:303.
  8. Shoback D. Clinical practice. Hypoparathyroidism. N Engl J Med 2008; 359:391.
  9. Goltzman D, Cole DEC. Hypoparathyroidism. In Primer on the Metabolic Bone Diseases and Disorders of Mineral Metabolism, American Society of Bone and Mineral Research 2006; 6:216.
  10. Mortensen L, Hyldstrup L, Charles P. Effect of vitamin D treatment in hypoparathyroid patients: a study on calcium, phosphate and magnesium homeostasis. Eur J Endocrinol 1997; 136:52.
  11. Kurokawa K. Calcium-regulating hormones and the kidney. Kidney Int 1987; 32:760.
  12. Gesek FA, Friedman PA. On the mechanism of parathyroid hormone stimulation of calcium uptake by mouse distal convoluted tubule cells. J Clin Invest 1992; 90:749.
  13. Winer KK, Yanovski JA, Cutler GB Jr. Synthetic human parathyroid hormone 1-34 vs calcitriol and calcium in the treatment of hypoparathyroidism. JAMA 1996; 276:631.
  14. Porter RH, Cox BG, Heaney D, et al. Treatment of hypoparathyroid patients with chlorthalidone. N Engl J Med 1978; 298:577.
  15. Santos F, Smith MJ, Chan JC. Hypercalciuria associated with long-term administration of calcitriol (1,25-dihydroxyvitamin D3). Action of hydrochlorothiazide. Am J Dis Child 1986; 140:139.
  16. Winer KK, Ko CW, Reynolds JC, et al. Long-term treatment of hypoparathyroidism: a randomized controlled study comparing parathyroid hormone-(1-34) versus calcitriol and calcium. J Clin Endocrinol Metab 2003; 88:4214.
  17. Winer KK, Yanovski JA, Sarani B, Cutler GB Jr. A randomized, cross-over trial of once-daily versus twice-daily parathyroid hormone 1-34 in treatment of hypoparathyroidism. J Clin Endocrinol Metab 1998; 83:3480.
  18. Winer KK, Sinaii N, Peterson D, et al. Effects of once versus twice-daily parathyroid hormone 1-34 therapy in children with hypoparathyroidism. J Clin Endocrinol Metab 2008; 93:3389.
  19. Rubin MR, Sliney J Jr, McMahon DJ, et al. Therapy of hypoparathyroidism with intact parathyroid hormone. Osteoporos Int 2010; 21:1927.
  20. Rubin MR, Dempster DW, Sliney J Jr, et al. PTH(1-84) administration reverses abnormal bone-remodeling dynamics and structure in hypoparathyroidism. J Bone Miner Res 2011; 26:2727.
  21. Sikjaer T, Rejnmark L, Rolighed L, et al. The effect of adding PTH(1-84) to conventional treatment of hypoparathyroidism: a randomized, placebo-controlled study. J Bone Miner Res 2011; 26:2358.
  22. Mannstadt M, Clarke BL, Vokes T, et al. Efficacy and safety of recombinant human parathyroid hormone (1-84) in hypoparathyroidism (REPLACE): a double-blind, placebo-controlled, randomised, phase 3 study. Lancet Diabetes Endocrinol 2013; 1:275.
  23. Silverberg SJ. Vitamin D deficiency and primary hyperparathyroidism. J Bone Miner Res 2007; 22 Suppl 2:V100.
  24. Cundy T, Haining SA, Guilland-Cumming DF, et al. Remission of hypoparathyroidism during lactation: evidence for a physiological role for prolactin in the regulation of vitamin D metabolism. Clin Endocrinol (Oxf) 1987; 26:667.
  25. Rude RK, Haussler MR, Singer FR. Postpartum resolution of hypocalcemia in a lactating hypoparathyroid patient. Endocrinol Jpn 1984; 31:227.
  26. Blickstein I, Kessler I, Lancet M. Idiopathic hypoparathyroidism with gestational diabetes. Am J Obstet Gynecol 1985; 153:649.
  27. Callies F, Arlt W, Scholz HJ, et al. Management of hypoparathyroidism during pregnancy--report of twelve cases. Eur J Endocrinol 1998; 139:284.
  28. Kurzel RB, Hagen GA. Use of thiazide diuretics to reduce the hypercalciuria of hypoparathyroidism during pregnancy. Am J Perinatol 1990; 7:333.
  29. Salle BL, Berthezene F, Glorieux FH, et al. Hypoparathyroidism during pregnancy: treatment with calcitriol. J Clin Endocrinol Metab 1981; 52:810.
  30. Caplan RH, Beguin EA. Hypercalcemia in a calcitriol-treated hypoparathyroid woman during lactation. Obstet Gynecol 1990; 76:485.
  31. Sadeghi-Nejad A, Wolfsdorf JI, Senior B. Hypoparathyroidism and pregnancy. Treatment with calcitriol. JAMA 1980; 243:254.
  32. Kovacs CS, Kronenberg HM. Maternal-fetal calcium and bone metabolism during pregnancy, puerperium, and lactation. Endocr Rev 1997; 18:832.
  33. Caplan RH, Wickus GG. Reduced calcitriol requirements for treating hypoparathyroidism during lactation. A case report. J Reprod Med 1993; 38:914.
  34. Sowers MF, Hollis BW, Shapiro B, et al. Elevated parathyroid hormone-related peptide associated with lactation and bone density loss. JAMA 1996; 276:549.
  35. Mantovani G. Clinical review: Pseudohypoparathyroidism: diagnosis and treatment. J Clin Endocrinol Metab 2011; 96:3020.
  36. Furukawa Y, Sohn H, Unakami H, Yumita S. Treatment of pseudohypoparathyroidism with 1 alpha-hydroxyvitamin D3. Contrib Nephrol 1980; 22:68.