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Last Updated: 2/11/2013  

Hypocalcemia

Diagnosis
  • Ask about perioral and acral paresthesias, muscle cramps, stiffness, and carpal-pedal spasm.

  • Look for:

    • Trousseau and Chvostek signs

    • Tetany, seizures, and papilledema characteristic of acute hypocalcemia

    • Cataracts, dental defects, skin changes, extrapyramidal disorders, and basal ganglia calcifications characteristic of chronic hypocalcemia

    • Bony tenderness characteristic of osteomalacia

  • Calculate the corrected serum calcium (calcium falls 0.8 mg/dL for every 1.0-g/L decrease in serum albumin) and/or measure ionized-calcium level

  • Obtain a serum intact PTH level.

  • Obtain serum phosphorus, alkaline phosphatase, electrolytes, magnesium, and 25-(OH) vitamin D or 1,25-(OH) vitamin D for most patients.

Hospitalization
  • Hospitalize patients with symptomatic hypocalcemia.

  • Hospitalize patients with ionized calcium <0.7 mg/dL or total calcium <6.5 mg/dL and/or a prolonged QT interval on ECG, even if asymptomatic and treat with 10 to 20 mL of 10% IV calcium gluconate over 5 to 10 minutes.

Therapy
  • Administer vitamin D and calcium to maintain the serum calcium 8.5 to 9.0 mg/dL.

  • Treat patients with kidney disease with 1,25-(OH)2 vitamin D3 due to the impaired ability to convert 25-(OH) vitamin D3 to its active form.

  • Treat patients with liver disease with 25-(OH) vitamin D3 due to the impaired ability to hydroxylate vitamin D.

  • Treat other patients with a vitamin D2 that has lowest overall cost.

  • Ensure daily intake of 1500 to 2000 mg/d of elemental calcium through diet or calcium supplementation.

  • Provide recombinant parathyroid hormone (teriparatide) therapy in patients with hypoparathyroidism who have persistent hypocalcemia despite calcium and calcitriol.

  • Treat hypocalcemia caused by hypomagnesemia with magnesium repletion.

DOI: 10.7326/d258
The information included herein should never be used as a substitute for clinical judgment and does not represent an official position of ACP.
Disclosures:
Suzanne M. Jan de Beur, MD has no financial relationships with pharmaceutical companies, biomedical device manufacturers, or health-care related organizations. Mary D. Ruppe, MD has no financial relationships with pharmaceutical companies, biomedical device manufacturers, or health-care related organizations.
Deborah Korenstein, MD, FACP, Editor in Chief, ACP Smart Medicine, has no relationships with any entity producing, marketing, re-selling, or distributing health care goods or services consumed by, or used on, patients. Richard B. Lynn, MD, FACP, Editor, ACP Smart Medicine, has no relationships with any entity producing, marketing, re-selling, or distributing health care goods or services consumed by, or used on, patients.
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