Hypercalcemia

The severity of the symptoms of hypercalcemia does not depend on how high the calcium levels are. They vary from person to person, and older individuals generally experience more symptoms than younger individuals. These symptoms develop slowly, irrespective of the cause. Some of the mild to moderate symptoms may include:

• Loss of appetite
• Nausea and vomiting
• Constipation
• Abdominal pain
• Polydipsia (excessive thirst)
• Polyuria (frequent urination)
• Peptic ulcers
• Pancreatitis
• Osteoporosis
• Osteomalacia
• Arthritis
• Pathological fractures
• Fatigue/tiredness
• Weakness
• Muscle pain
• Confusion and disorientation
• Headaches
• Difficulty concentrating
• Depression

Serious symptoms can include:

• Seizure
• Irregular heartbeat
• Heart attack
• Loss of consciousness
• Coma

Calcium is essential for building strong bones and teeth, muscle contraction, and nerve signal transmission. The parathyroid glands secrete a hormone when calcium levels in the blood decrease, which triggers:

• Bones to release calcium into the bloodstream
• The digestive tract to absorb more calcium
• Kidneys to excrete less calcium and activate Vitamin D, which plays a vital role in calcium absorption

Common conditions associated with hypercalcemia can be divided into two major categories: parathyroid hormone (PTH) causes and non-parathyroid hormone causes. They are as follows:

Parathyroid hormone causes of hypercalcemia

• Hyperparathyroidism: A condition caused by an overactive parathyroid gland, it is the most common cause of hypercalcemia. It can result from a noncancerous (benign) tumor or enlargement of one or more of the four parathyroid glands.
• Hereditary factors: A rare genetic disorder known as familial hypocalciuric hypercalcemia leads to increased calcium levels in the blood due to defects in calcium receptors in the body.
• Endocrine causes: These include diseases such as thyrotoxicosis (stimulation of osteoclasts by thyroid hormone), hypoadrenalism (decreased functioning of the adrenal glands, also known as Addison’s disease), and pheochromocytomas (hormone-secreting tumors that can occur in the adrenal glands).
• Medications: Certain drugs, such as thiazide diuretics (used to treat high blood pressure) and lithium (used to treat bipolar disorder), can increase the release of parathyroid hormone, leading to hypercalcemia.
• Cancer: Lung cancer, breast cancer, kidney cancer, some blood cancers like multiple myeloma, and the spread of cancer (metastasis) to the bones can increase the risk of hypercalcemia.

Non-parathyroid hormone causes of hypercalcemia

• Supplements: Excessive intake of calcium or Vitamin D supplements over time can raise calcium levels in the blood above the normal range.
• Immobility: Hypercalcemia can develop in individuals with conditions that cause prolonged sitting or lying down, due to the release of calcium into the blood from bones that do not bear weight.
• Severe dehydration: Reduced fluid in the blood can cause a rise in calcium concentrations, leading to mild or transient hypercalcemia. The severity depends on kidney function; in individuals with long-term kidney disorders, the effect of dehydration is greater.
• Other diseases: Tuberculosis and sarcoidosis are lung diseases that can elevate Vitamin D levels in the blood, stimulating the digestive tract to absorb more calcium. Paget's disease has also been linked to increased calcium levels.

Any risk factor that puts an individual at risk for developing hyperparathyroidism or having overactive thyroid glands is also at risk of developing hypercalcemia. Common risk factors of hypercalcemia include:

• Women in the postmenopausal age.
• Older individuals in their 50s or 60s.
• Family history of hyperparathyroidism.
• Past history of familial syndromes such as multiple endocrine neoplasia (diseases affecting the hormone-producing endocrine system) type 1, type 2A, or type 4.
• Familial hypocalciuric hypercalcemia (an inherited disorder that causes abnormally high levels of calcium in the blood and low to moderate levels of calcium in the urine).
• Hyperparathyroid-jaw tumor syndrome (a condition characterized by overactivity of the parathyroid glands).

Less common risk factors of hypercalcemia include:

• Any past or current history of lithium use.
• Radiation exposure to the head and neck region.

Note: Hypercalcemia generally presents with mild or no symptoms in many cases and may go unnoticed. With timely preventive health check-ups, one can spot and address risk factors for certain diseases that might arise with old age. Learn more about the need for preventive health check-ups for the elderly.

Hypercalcemia can cause very few signs or symptoms, and individuals may not know they have the disorder until routine blood tests, such as serum calcium, help determine if hypercalcemia is present. Blood tests can also show whether parathyroid hormone (PTH) levels are high, indicating hyperparathyroidism. If hyperparathyroidism has been excluded, further tests will be required to determine whether the cause of hypercalcemia is associated with malignancy. In these cases, PTH levels will be undetectable, and further tests are conducted, including:

• Erythrocyte sedimentation rate (ESR): This test indicates the presence of inflammation in the body but does not identify the cause.
• Immunoglobulin panel: This test measures the levels of specific immunoglobulins or antibodies in the blood.
• Protein electrophoresis: This test identifies unique proteins in the body that are present in certain types of cancer.
• Bence Jones proteins: This test measures the levels of Bence Jones protein in the urine, which is specifically produced by plasma cells that provide immunity to the body.
• Chest X-ray: An imaging test that uses X-rays to examine the structures and organs in the chest and detect certain lung and heart problems.
• Liver function tests (LFTs): A group of blood tests commonly performed to evaluate liver function.
• Abdominal ultrasound: This test creates images of organs in the abdomen, including the liver, gallbladder, spleen, pancreas, and kidneys.
• Imaging of bones: A specialized radiology procedure used to examine the various bones of the skeleton.
• Genetic testing: Gaining importance lately, genetic testing is becoming a routine part of the investigation of hypercalcemia, especially when there is a relevant family history.

Not all hypercalcemia can be prevented, but the following recommendations may help:

• Avoid excess intake of calcium pills and calcium-based antacid tablets.
• Consult with a doctor if there is any family history of high calcium, kidney stones, or parathyroid conditions.
• Avoid taking dietary supplements, vitamins, or minerals without first discussing them with a doctor.

Changes in blood calcium levels can also be linked to cancer. Therefore, the most effective way to control calcium levels is to treat the underlying cancer itself.

In the case of mild to moderate hypercalcemia, monitoring the bones and kidneys over time to ensure they are healthy is the best option. In severe cases of hypercalcemia, medications or treatment of the underlying disease, including surgery, might be required.

A. Medications

The most recommended medications include:

• Drugs acting on osteoclasts
  • Calcitonin: This hormone regulates calcium levels in the blood. It acts as a calcitonin receptor agonist by suppressing the activity of osteoclasts (bone-destroying cells).
  • Mithramycin: This drug blocks the function of osteoclasts and is often administered to patients with malignancy-associated hypercalcemia (MAH). It can cause severe toxicity in the kidneys, liver, and bone marrow.
• Drugs used in cancer-related hypercalcemia
  • Bisphosphonates: These drugs lower calcium levels and are used to treat hypercalcemia due to cancer.
  • Denosumab: This drug is used for treating cancer-caused hypercalcemia in patients who do not respond well to bisphosphonates.
  • Pamidronate: This can be administered intravenously in patients with malignancies. It often normalizes serum calcium levels, has a rapid onset but a short duration of effect, and patients can develop tolerance to its calcium-lowering effect.
  • Prednisone: Short-term use of steroid pills such as prednisone is typically helpful in hypercalcemia caused by high levels of Vitamin D, myeloma, and lymphoma.
• Other drugs
  • Cinacalcet: This drug is approved for managing hypercalcemia and acts by controlling overactive parathyroid glands.
  • IV fluids and diuretics: These may be required in emergencies to lower calcium levels and prevent heart rhythm problems or damage to the nervous system.
  • Ketoconazole: This antifungal drug is used in hypervitaminosis D (excessive Vitamin D in the body) to prevent toxicity and overproduction of calcium.

B. Dialysis

In severe cases of resistant, life-threatening hypercalcemia, hemodialysis (a treatment to filter wastes and water from the blood) is effective in lowering serum calcium levels.

C. Surgery

In hyperparathyroidism leading to hypercalcemia, urgent parathyroidectomy (removal of the affected parathyroid gland) is potentially curative. In most cases, only one of the four parathyroid glands is affected.

A special test is used to scan and pinpoint the gland or glands that are not functioning properly. This procedure involves injecting a small dose of radioactive material into the glands.

Mild hypercalcemia may not require any treatment. However, if the condition is more serious or severe, the doctor may prescribe medications to lower the levels of calcium along with treating the underlying cause. Certain lifestyle modifications can help keep calcium levels balanced and bones healthy. They are:

• Stay hydrated
  Drinking water can lower blood calcium levels and prevent kidney stones. Make sure to keep a bottle of water nearby at night.
• Quit smoking
  Smoking can increase the risk of bone loss and cancer. In addition to improving general health, quitting smoking will reduce the risk of cancer and other health problems. Tobacco is injurious to health. Say no to tobacco. Try our smoking cessation product range.
• Exercise regularly
  Staying active is key to promoting good health. Resistance training can help improve bone strength and health.
• Follow proper medical advice
  Decrease the risk of consuming too much Vitamin D or calcium supplements and developing hypercalcemia. Use antacids that contain magnesium and avoid those with high calcium content. Talk to the doctor about what medicines and herbs are safe in case of hypercalcemia.
• Have a balanced diet
  Decrease the number of dairy foods like cheese, milk, yogurt, and ice cream. Avoid food items like okra, spinach, soya, and bread that have high levels of calcium. Read food labels carefully and skip items that have high calcium content to ensure the right quantity.

Every person is different, and so are the nutritional requirements. There are some dietary guidelines that one should follow for a proper balanced diet. Understand how to reap benefits from your diet. If the doctor has prescribed medications to keep the calcium levels in control, take them in the right way and the right quantity. Call the doctor if there are any side effects.

Hypercalcemia complications can range from manageable to being fatal. They include:

• Osteoporosis: Also known as bone-thinning disease, this condition occurs as bones continue to release calcium into the blood, potentially leading to bone fractures, spinal column curvature, and loss of height.
• Kidney stones: The formation of crystals in the kidneys due to excessive calcium in the blood can lead to kidney stones. Passing a stone during urination can be extremely painful.
• Kidney failure: This complication occurs in severe hypercalcemia and can damage the kidneys, limiting their ability to cleanse the blood and eliminate fluid.
• Arrhythmia: Hypercalcemia can lead to an irregular heartbeat, as increased calcium levels may affect the electrical impulses that regulate the heartbeat.
• Nervous system problems: Hypercalcemia can result in confusion, dementia, and coma in severe cases.

Some of the other complications of hypercalcemia include:

• Depression
• Bone pain
• Constipation
• Pancreatitis
• Gastric ulcers
• Paresthesias
• Syncope

Mild to moderate symptoms of hypercalcemia can be managed by certain lifestyle modifications and prescribed medications. However, there is ongoing research to reduce calcium levels through alternative medicine. Some of these therapies include:

1. Herbal Therapy

Herbs are sometimes used to counter the bone loss that can occur from hyperparathyroidism, though scientific studies on their effectiveness are limited. They are generally available as standardized dried extracts, such as pills, capsules, tablets, teas, or tinctures/liquid extracts. It is important to consult a doctor before taking any herbs, especially in cases of hypercalcemia due to hyperparathyroidism. The following herbs have shown positive results in lowering calcium levels:

• Chaste tree (Vitex agnus castus)
• Dandelion (Taraxacum officinale)
• Fructus ligustri lucidi (FLL)

2. Physical Therapy

A sedentary lifestyle can cause longer bones to absorb calcium, leading to hypercalcemia. Engaging in physical activity and physical therapy has proven effective in these cases. Common benefits of this therapy include:

• Weight-bearing exercises help prevent osteoporosis and immobility
• Prevention of fractures
• Increased strength and range of motion (ROM)

The severity of hypercalcemia depends on the cause. When hypercalcemia is due to hyperparathyroidism, symptoms tend to be mild but prolonged. However, hypercalcemia due to malignancy can have severe symptoms and poor quality of life due to aggressive treatment modalities. The mild symptoms of hypercalcemia can be managed by following certain simple lifestyle changes:

• Stop taking calcium supplements.
• Avoid medications containing calcium carbonate, which are generally used to treat acid reflux.
• Stay active to keep the digestive system moving.
• Avoid long periods of inactivity and a sedentary lifestyle.
• Drink plenty of liquids and stay hydrated, as hydration aids the body in breaking down food.
• Abstain from consuming large quantities of calcium-rich foods.
• Do not completely deprive the body of calcium-rich foods, as they are required for other functional nutrients.
• Talk to your doctor before making any drastic changes and develop a plan that best suits your needs.
• Quit smoking.