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Causes of Hypercalcemia (AIPG 06, AIIMS Nov 06) (Ref. Hari. 18th ed., Pg-3099, table 353.1) 

  1. Lithium, Thiazide, Phenytoin
  2. Ca of breast, Lung kidney, MM, lymphoma
  3. Vit D intoxication, Vit A intoxication, Aluminium intoxication
  4. Hyperparathyroidism, Hyperthyroid, Pheochromocytoma, MEN
  5. Sarcoidosis
  6. Prolong Immobilization
  7. Milk alkali syndrome
  8. Familial hypercalciuric hypercalcemia 

Important Points: (Ref. Hari. 18th ed., Pg- 3110, Fig 353-6)

  1. Causes of Hypercalcemia with increase PTH
    1. Hyperparathyroid (Primary, Secondary, Tertiary)
    2. MEN Syndrome
    3. Familial Hypocalciuru Hypercalcemia.
  2. In all other causes of hypercalcemia , the PTH level is low !!!.

Management of Acute hypercalcemia

  1. Mild hypercalcemia (up to)­ 12 mg/dl → Managed by hydration alone
  2. More severe hypercalcemia 13 to 15 mg/dl   Hydration with saline Forced diuresis: saline : Loop diuretics (Furosemide) promotes calcium excretion
Extra Edge:

Thiazide cause hypercalcemia so are never used in the treatment of hypercalcemia.


Therapy for chronic hypercalcemia (Ref. Hari. 18th ed., Pg-3111, table 353.4)


Most useful therapies

  1. Bisphosphonates : Bisphosphonates reduce calcium resorption
    1. 1st generation       Etidronate
    2. 2nd generation      Pamidronate
    3. 3rd generation       Zoledronate

Note: Biphosphonate can cause intense esophagitis

  1. Glucocorticoids : Effective in particular situations such as Vitamin D intoxication, Sarcoidosis, Malignancy
  2. Calcitonin
  3. Phosphate:
  4. Dialysis  -  Quick and effective and is likely to be needed in severe cases with renal failure
  5. Plicamycin
  6. Gallium Nitrate
Extra Edge:

Strontium is new compound which causes both increase osteoblastic and reduce osteoclastic activity thereby it causes both bone formation and reduces bone resorption. (AIIMS NOV 2011)


Extra Edge (Ref. Hari. 18th ed., pg - 3131)
  1. Nitrogen-containing bisphosphonates like zoledronic acid or pamidronate can disrupts intracellular protein trafficking and ultimately may lead to apoptosis.
  2. So osteonecrosis of the jaw (ONJ) can occur, mostly in patients with cancer, who are given high doses of zoledronic acid or pamidronate.
  1. Surgical excision of the adenoma

Table - Indications for Surgery in Primary Hyperparathyroidism


Symptoms related to hypercalcemia
  1. Age <50 years
  2. Renal manifestations
  3. Renal calculi
  4. Reduced creatinine clearance
  5. 24-hour urine calcium excretion >400 mg/dL
  6. Bone mineral density >2.5 SDs below peak bone mass (t-score)
  7. Patient preference for surgery or unwillingness/inability to undergo prolonged follow-up

SD = standard deviation.


Extra Edge:

Cinacalcet is new drug.

  1. It is a calcimimetic agent that reduces the parathormone level. 
  2. It is use in treatment of secondary hyperparathyroidism.
  3. It is also used for treatment of hypercalcemia in patient with parathyroid adenoma.


Extra Edge:


  1. It is an orally administered bisphosphonate, inhibits osteoclast-mediated resorption of bone, and modulates bone metabolism in women with postmenopausal osteoporosis. 
  2. The long half-life of risedronate (480 hrs) for once a –week administration.

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