calcium

normal levels of Ca

•8.5-10.1 mg/dL

more than 99% of the ca in the body is found in the…

bone

functions of Ca

•Transmission of nerve impulses, skeletal muscle contraction, myocardial contractions, maintenance of normal cellular permeability, formation of bones/teeth

•Reciprocal relationship between serum Ca and ___

phos

ca is regulated by

PTH

vitamin D

calcitonin

causes of hypocalcemia

•Inadequate intake

•Excessive losses

•Hypomagnesemia

•Medications

Blood product infusion (chelation by citrate buffers)

symptoms of hypocalcemia occur when Ca is ____ or when ionized Ca is ___

<6.5

<1.2

symptoms due to hypocalcemia

•Tetany, circumoral tingling, muscle spasms, hypoactive reflexes, anxiety, hallucinations, hypotension, MI, seizures, lethargy, stupor

oral tx options for hypocalcemia

calcium carbonate

calcium citrate

IV tx options for hypocalcemia

Ca chloride

Ca gluconate

which IV tx is pref for hypocalcemia

calcium gluconate due to less vein irritation

calcium chloride IV must be given

central line

IV calcium supplement can be given

IV push or slow infusion

tx for chronic and asymptomatic hypocalcemia

•Oral calcium at 2-4 g/day elemental calcium

chronic and asymptomatic hypocalcemia tx with oral calcium can cause

constipation

chronic and asymptomatic hypocalcemia often occurs with which other deficiency

vit D

acute symptomatic hypocalcemia tx

•Administer IV calcium until symptoms are controlled while monitoring levels

•Calcium chloride or calcium gluconate 1 gram IV and repeat doses as necessary

mild hyperCa

10.2-12.0

moderate hyperCa

12.1-14.0

severe hyperCa

> 14

causes of hyperCa

•Hyperparathyroidism, malignancy, Paget disease, Addison disease, granulomatous disease, hyperthyroidism, immobilization, multiple bony fractures, acidosis

•Medications

first line tx for hyperCa

isotonic saline solution

isotonic saline

tx for ____

MOA ____

onset ____

duration ___

hyper Ca

restoration of intravascular volume, increases urinary Ca excretion

hours

during infusion

calcitonin

tx for ____

MOA ____

onset ____

duration ___

hyper Ca

inhibits bone resorption by interfering with osteoclasts, increases urinary ca excretion

4-6 hours

48 hours

Bisphosphates

tx for ____

MOA ____

onset ____

duration ___

hyperCa

inhibits bone resorption by interfering with osteoclasts

34-72 hours

2-4 weeks

Loop diuretics

tx for ____

MOA ____

onset ____

duration ___

hyperCa

increases urinary calcium excretion

hours

during tx

denosumab

tx for ____

MOA ____

onset ____

duration ___

hyperCa

inhibits bone resoprtion via inhibition of RANKL

4-10 days

4-15 weeks

dialysis

tx for ____

MOA ____

onset ____

duration ___

hyperCa

low or no calcium dialysate

hours

during tx

mild/ moderate hyperCa and asymptomatic tx

•May not require immediate treatment

•Avoid factors that can aggravate hypercalcemia

•Thiazide diuretics, volume depletion, prolonged bed rest, high calcium diet

severe hyperCa or symptomatic tx

•Isotonic saline at initial rate of 200-300 ml/hr + loop diuretics (HF or renal insufficiency)

•Calcitonin 4 IU/kg IM or SQ and can be repeated every 6-12 hours for max of 48 hours (Duration of calcitonin is limited to 48 hours due to development of tachyphylaxis)

•Zoledronic acid 4 mg IV or pamidronate 60-90 mg IV

rec combo of ___ for severe and symptomatic hyperCa

fluids + calcitonin + bisphosphonate

which bisphosphonate is pref for malignancy

zoledronic acid

long term use fo bisphosphonate is assoc with

osteonecrosis of jaw

bisphosphonate Ci

severe renal impairment

allergy

dose of denosumab

60-120 mg subq a week

monitor for ___ when taking bisphonate

hypocalcemia