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Last Updated: 11/15/2013  


  • Recognize that hypercalcemia is most often asymptomatic but can be present in patients with nonspecific symptoms or unexplained dehydration and confusion.

  • Ask patients about history relevant to hypercalcemia including malignancy, nephrolithiasis, granulomatous disease, and endocrine tumors.

  • Measure serum calcium and albumin to diagnose hypercalcemia; diagnose hypercalcemia if the serum calcium level is ≥10 mg/dL.

  • Measure intact PTH to differentiate between parathyroid- and nonparathyroid-mediated disease.

  • If PTH levels are low, check other diagnostic tests to narrow the differential diagnosis, beginning with a malignancy work-up.

  • If PTH levels are high or inappropriately normal, check 24-hour urine calcium to differentiate between hyperparathyroidism and familial hypocalciuric hypercalcemia.

  • Begin rehydration as the initial therapy for acute hypercalcemia.

  • Treat patients with malignancy-associated hypercalcemia who remain hypercalcemic after rehydration with an intravenous bisphosphonate.

  • Consider administering calcitonin or glucocorticoids in patients critically ill with hypercalcemia.

  • Consider parathyroidectomy in patients with primary hyperparathyroidism.

  • For patients with primary hyperparathyroidism, consider therapy with alendronate, estrogen, or raloxifene for skeletal protection in postmenopausal women with primary hyperparathyroidism and consider cinacalcet to treat hypercalcemia.

  • For patients with hypercalcemia due to granulomatous diseases such as sarcoidosis, consider initiating corticosteroids.

DOI: 10.7326/d177
The information included herein should never be used as a substitute for clinical judgment and does not represent an official position of ACP.
Author(s) and Disclosures:
Michael Kleerekoper, MD is a consultant for Merck, Lilly, Proctor and Gamble, Aventis, Wyeth, Novartis, received honorarium from Merck, Lilly, Proctor and Gamble, Aventis, Wyeth, Novartis, received grants from Wyeth. Sudha Reddy, MB, BS has no financial relationships with pharmaceutical companies, biomedical device manufacturers, or health-care related organizations. Aliya Khan, MD, FRCPC, FACP, FACE received consultancy fees and honoraria from Amgen, Lilly, Merck, and Novartis; received grants from Amgen, Merck, and NPS.

One or more of the present or past ACP Smart Medicine physician editors worked on this module and had nothing to disclose: Davoren Chick, MD, FACP; Deborah Korenstein, MD, FACP; Marjorie Lazoff, MD, FACP; Richard Lynn, MD, FACP.

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