JAMA Clinical Reviews Hypercalcemia—A Review
Oct 25, 2022
Elizabeth Shane, an endocrinologist and professor specializing in metabolic bone disease, guides the clinical approach to hypercalcemia. She explains lab definitions and when to measure ionized calcium. She covers distinguishing PTH-mediated versus non‑PTH causes, surgical criteria for primary hyperparathyroidism, urgent care for malignancy-related hypercalcemia, and follow-up strategies for conservatively managed patients.
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Hypercalcemia Defined By Local Lab Range
- Hypercalcemia is defined relative to the lab's reference range using albumin-corrected serum calcium.
- A calcium of 12 mg/dL is universally abnormal, whereas values near the upper limit (eg 10.2 mg/dL) depend on each lab's normal range.
Measure Ionized Calcium Only When Clinical Context Requires
- In outpatients, measure total serum calcium and correct for albumin; reserve ionized calcium for ICU patients or those with acid-base or major albumin disturbances.
- Use ionized calcium when acid-base status or rapidly changing albumin binding could mislead total calcium interpretation.
Follow Borderline Calcium Trends Before Acting
- For borderline or fluctuating calcium values, follow the patient over time rather than react to a single marginal result.
- Many patients with consistent mild hypercalcemia will have occasional normal days and can be safely observed until a pattern emerges.