Acute Management of Hypercalcaemia Document Control Title Acute Management of Hypercalcaemia Author Author’s job title Medical consultant Directorate Department Medicine Medical Assessment Unit/Medicine Date Version Status Comment / Changes / Approval Issued 0.1 Jan Draft Initial version for consultation 2019 1.0 May Final Approved by Drugs and Therapeutics Committee 16th May 2019 2019. Main Contact Gastroenterologist or Clinical Tel: Direct Dial – effectiveness lead Tel: Internal – Medical Assessment Unit North Devon District Hospital Raleigh Park Barnstaple, EX31 4JB Lead Director Medical clinical lead Superseded Documents Issue Date Review Date Review Cycle May 2019 May 2022 Three years Consulted with the following stakeholders: Medical Trust grade Clinical Effectiveness Lead Gastroenterologist and Clinical lead for medicine Biochemical Sciences lead Pharmacist Approval and Review Process Drugs and Therapeutics Local Archive Reference G:\\ Acute Management of Hypercalcaemia Local Path General Medicine - Acute Management of Hypercalcaemia Filename Acute Management of Hypercalcaemia Policy categories for Trust’s internal Tags for Trust’s internal website (Bob) website (Bob) Hypercalcaemia, bisphosphonates, Pharmacy Calcium, Workforce Zoledronic acid, Pamidronate General Medicine Page 1 of 10 Acute Management of Hypercalcaemia Contents Document Control ............................................................................................................... 1 1. Purpose ........................................................................................................................ 3 2. Definition of hypercalcaemia ...................................................................................... 3 3. Definition of ionised versus adjusted calcium ........................................................... 3 4. Responsibilities ........................................................................................................... 3 5. Hypercalcaemia ............................................................................................................ 4 6. Causes .......................................................................................................................... 5 7. Assessment .................................................................................................................. 5 8. Management ................................................................................................................. 6 9. Further management considerations ......................................................................... 7 10. Monitoring Compliance with and the Effectiveness of the Policy ............................ 8 11. Equality Impact Assessment ....................................................................................... 8 12. References ................................................................................................................... 9 13. Associated Documentation ......................................................................................... 9 14. Appendix 1 – Quick management reference guide .................................................. 10 General Medicine Page 2 of 10 Acute Management of Hypercalcaemia 1. Purpose The purpose of this document is to detail the process for management of hypercalcaemia in adults The policy applies to all staff involved in managing patients with hypercalcaemia Implementation of this policy will ensure that: Hypercalcaemia is identified and managed appropriately and in a timely fashion There is a standard pathway to follow across the trust The information is readily available 2. Definition of hypercalcaemia Normal adult (adjusted) calcium level: 2.20-2.60mmol/l Mild: 2.60-3.00 (not usually medical emergency, usually asymptomatic ) Moderate: 3.00-3.50 (can be medical emergency, can be symptomatic) Severe: >3.50 (usually a medical emergency) 3. Definition of ionised versus adjusted calcium Calcium levels are often recorded as both ionised and adjusted Ionised – this is the physiologically active calcium Adjusted calcium – this calcium is bound to protein (mainly albumin) and so will be affected by changes in albumin level 4. Responsibilities 4.1. Role of Medical Director Ensuring adherence to the policy 4.2. Role of Clinicians Identifying and recognising hypercalcaemia and managing it according to policy guidelines, unless good reasons exist to deviate from the guidance. General Medicine Page 3 of 10 Acute Management of Hypercalcaemia 4.3. Role of Nursing Staff To adhere to policy guidelines and treat patients appropriately and in a timely manner, and recognising unsafe prescriptions. 4.4. Role of Pharmacy Staff To provide advice and guidance in line with policy, recognising unsafe prescriptions where possible. 4.5. Role of Biomedical Scientists Carrying out investigations and informing clinical staff in a timely fashion of abnormal results requiring urgent action Laboratory staff will call clinical teams if adjusted calcium levels are above 2.8 mmol/L 4.6. Role of Drugs and Therapeutics Group The Drugs and Therapeutics Group is responsible for: Acting as an oversight for the policy Confirming and publishing the policy 5. Hypercalcaemia 5.1. Background 99% of calcium in adults is held within bone. Serum concentration tightly regulated. Intracellular compartments very sensitive to change. It is highly bound to albumin, and therefore should be adjusted for serum albumin levels Critical in many essential roles within the body, including clotting, muscle contraction, nerve conduction, insulin release and bone structure. General Medicine Page 4 of 10 Acute Management of Hypercalcaemia 5.2. Signs and symptoms Symptoms usually arise with a corrected level above 3.0mmol/l “Moans, bones, stones, groans, psychological overtones” Loss of appetite, nausea and vomiting, abdominal pain, constipation Polyuria and polydipsia Fatigue, weakness, muscle aches. Confusion, depression, headache, coma Renal calculi/colic, renal impairment, calcified vessels/organs, band keratopathy (calcified cornea) Pancreatitis Reduced QTc, dysrhythmias, cardiomyopathy 6. Causes 90% of hypercalcaemia cases due to hyperparathyroidism or malignancy 6.1. Less common causes Endocrine: primary hyperparathyroidism, tertiary hyperparathyroidism, adrenal insufficiency, thyrotoxicosis Metabolic: dehydration, rhabdomyolysis, familial hypocalciuric hypercalcaemia,, milk alkali syndrome, Paget’s disease, phaechromocytoma Medication: calcium supplements, thiazide diuretics, lithium, theophylline toxicity, hypervitaminosis D and A (rare) Granulomatous disease: e.g. sarcoid 7. Assessment 7.1. History Key points see signs and symptoms. Include Night sweats, weight loss Cough, GI symptoms Medications, including over the counter Family history General Medicine Page 5 of 10 Acute Management of Hypercalcaemia 7.2. Examination Assess cognitive impairment, Fluid status, Check for underlying cause neck/lymph nodes/ respiratory/abdomen/ breast 7.3. Initial investigations ECG – look for short QTc or other conduction abnormalities Calcium, phosphate, U+E and PTH 8. Management 8.1. Acute management (see appendix 1) Review of medications, e.g. calcium and vitamin D supplements, diuretics Rehydrate – 0.9% Sodium Chloride 4-6 litres over 24 hours, depending on severity - Caution regarding fluid overload, heart failure, renal failure and elderly - Consider dialysis in severe renal failure (discuss with senior or renal team) Once rehydrated if further treatment needed Bisphosphonates - Caution with renal impairment –especially if eGFR <30 Zoledronic acid 3 - 4mg in 100mls Sodium Chloride 0.9% over 15 minutes (lower dose in renal impairment or less severe hypercalcaemia) (see appendix 1) Pamidronate (see Appendix 1) Ibandronic acid 2-4mg – consider in renal impairment – seek senior advice and discuss with pharmacist, can be considered if eGFR <30 Consider steroids in lymphoma Monitor calcium levels daily General Medicine Page 6 of 10 Acute Management of Hypercalcaemia 9. Further management considerations Determine underlying cause – 90% are due to malignancy or hyperparathyroidism 9.1. Further Investigations Check albumin PTH, U+E, LFTs, phosphate, magnesium, TFTs ECG USS renal tract to explore for calcification or calculi 24 hour urinary calcium levels Imaging of parathyroid glands, e.g. USS or Nuclear Medicine 9.2. Second line treatments Calcium PTH Diagnosis High High Primary or tertiary hyperparathyoidism High Low Malignancy or other less common causes Calcitonin – consider if poor response to bisphosphonates – discuss with senior or endocrinologist Glucocorticoids (e.g. prednisolone 40mg) – helpful in lymphoma or granulomatous disease Calcimimetics (e.g. cinacalet) – for primary hyperparathyroidism Parathyroidectomy – consider in primary hyperparathyroidism if severe hypercalcaemia and poor response to other measures Nb. Loop diuretics can be helpful in fluid overload but do not lower calcium levels General Medicine Page 7 of 10 Acute Management of Hypercalcaemia 10. Monitoring Compliance with and the Effectiveness of the Policy 10.1. Standards/ Key Performance Indicators Key performance indicators comprise: Successful management of hypercalcaemia Number of patients with hypercalacaemia that are not resolved within 5 days Number of patients who have a cause of their hypercalcaemia diagnosed (or suspected diagnosis) within 5 days 10.2. Process for Implementation and Monitoring Compliance and Effectiveness