Beta - What is hypercalcemia?

What is hypercalcemia? So hypercalcemia, as the name suggests, is high calcium. And high calcium can be due to multiple causes. And also when we think about the levels for calcium, about the upper limit of normal is considered high calcium. There are different ranges, mild, moderate, and severe, based on the level. And generally cancer-related hypercalcemia are usually much higher than hypercalcemia related to something like primary hyperparathyroidism, which would be a milder or a lower calcium level. When we think about causes or what causes hypercalcemia, myeloma is of course one of But amongst other things, vitamin D intoxication or very high levels of vitamin D supplements, milk alkali syndrome, meaning taking too many calcium supplements, other things like primary hyperparathyroidism. So these are glands, the hyperparathyroid glands that sit behind the thyroid gland. And their job is to basically manage and maintain the calcium balance in our bodies. And if those glands get overactive and they're producing too much of a certain hormone called the parathyroid hormone, then that can lead to higher calcium levels too. So I think this is a very important point that somebody who has smoldering myeloma or MGAS and they have a high calcium level, we should not directly attribute it to them having progress to myeloma without having done a full workup to make sure some of the other causes are not what's causing it. So if it's not related to vitamin D intoxication or primary hyperparathyroidism or some other cause because if that's the case, then we shouldn't be treating them as myeloma yet. So I think that's important to differentiate. Other causes could be things like vitamin A excess too and certain drugs like hydrochlorothiazide, like the diuretics, some other drugs like tereparatide, which is used in osteoporosis. So I think it's important to also see if there are any drugs that might be raising the calcium level. How are high calcium levels monitored? Calcium levels are monitored by a blood test. Many times your doctors will do something like a comprehensive metabolic panel or a basic metabolic panel in the blood. And one of those markers in that panel is the calcium. And so with that, we can know the levels. One thing to note is calcium levels in the blood are very dependent on the albumin levels in the blood. So if the albumin is very low, you can have a falsely low calcium. So you have to monitor it in the context of the albumin and the doctors use a calculator often to correct the calcium or check a free calcium, ionized calcium level. So those are things if your albumin is low, you might want to discuss it with your doctor and think about it. What are the signs and symptoms of hypercalcemia? So hypercalcemia in terms of symptoms can sometimes be asymptomatic, meaning no symptoms when it's mild and it's gradual onset. But sometimes it can also be present with multiple symptoms. And one of the ways to remember it is groans, bones, moans, stones. And groans is abdominal pain, constipation, nausea, vomiting. It can cause pain and tenderness for some people. Stones in long term high calcium can cause kidney stones. And then moans is more like confusion, lethargy or psychiatric issues where you're not really your normal self. That can also happen. So these are some signs of hypercalcemia. And it can be sometimes very vague and you have to be thinking about it. It may just be an insidious onset of constipation or the person's just not feeling themselves. And those things we have to think about it and look in the blood, especially if we expect it or know it'll often happen when the myeloma is getting active again or things like that. How do you treat hypercalcemia? When we think about treatment for hypercalcemia, the first thing most important is basically treating the cause. Like why is this happening? So is it happening because of the cancer? Then we need to treat the cancer. Is it happening because of hyperparathyroidism? We need to treat that. If it's vitamin D intoxication, we need to stop the vitamin D. If it's calcium supplements, we need to stop that. But that all takes time to work and have the effect. So when we see the calcium initially, the doctor is going to make a decision on how to manage it urgently. Does it need urgent management or we can wait some time? If the levels are very high, often the patients may need admission or they may be managed outpatient, but they will need to come into the infusion centers or things like that. If the levels are mild or low, then it can be something that could be managed much more slowly or with observation. Some of the treatments that I used, one is IV fluids just to basically hydrate and get the more urination to excrete the calcium because sometimes dehydration also develops with high calcium levels. Another thing we do is something called furosemide, which is a medication that basically helps you urinate more, but it helps to actually excrete calcium too and lower the levels. Other things are bone strengtheners that you probably have heard about like for osteoporosis, like bisphosphonates, so Zometa or Zolandronic acid and Pimidronate. These two medications are bone strengtheners that are used for patients with myeloma and bone disease and patients with osteoporosis. They are also approved for hypercalcemia. If a patient has high calcium, your doctor may give you an IV infusion, one dose of that. However, its effect can take a few days to fully come into effect. If the levels are again dangerously high, your doctor may do something like calcitonin for few doses to bring the levels down more quickly, but that doesn't last long term. Zometa or the Pimidronate will work for the longer term. Other things, the last thing I would say is another drug called Dinozumab, which you probably have heard the names Prolia or X-Giva. Those are also drugs that can help bring the calcium levels down quickly, especially in somebody with advanced kidney disease where the other bisphosphonates are things we may not use. What is hypocalcemia? So hypocalcemia is basically low levels of calcium, levels below the lower limit of normal for your disease. In myeloma, hypocalcemia is less commonly seen as hypercalcemia is related to the disease. However, we do see hypocalcemia sometimes when we give these drugs like bisphosphonates or Dinozumab. And these drugs, bisphosphonates would be things like Zolendronic acid or Pimidronate. These drugs can cause lowering of the calcium levels. And it is important sometimes in these patients because it's pushing the calcium into the bones that then the blood levels drop. And some patients may need repletion with vitamin D and with calcium because if you don't have enough vitamin D, you're not going to absorb the calcium too. Those are the most common reasons why we as myeloma doctors and patients are going to see low calcium is because of the medications we give that lower the levels. Other things could be related to just nutrition or other health issues that may cause it. And when the calcium levels are low, the main thing is basically repleting it probably with supplements and identifying what the cause might be. What are signs and symptoms of low calcium? Another time where you might see hypocalcemia is during stem cell collection or apheresis. When the blood is passed through the machine, there is something called EDTA that may bind calcium and lower the levels. So many patients are given calcium supplements around that time and told to tell the doctor if they develop any symptoms. The symptoms of low calcium can be things like numbness around the mouth or lips or tremors in the hands or like a tetany where it's a spasm in the hands too. So those are some of the symptoms of a low calcium level. How are low calcium levels monitored? Calcium levels are monitored the same way with a basic metabolic panel or a comprehensive metabolic panel where your doctor can draw it or they might just draw the calcium level in the blood specifically. And like I said, albumin is a very important, affects the calcium levels. So often when they draw calcium, they're also going to check albumin levels as well to correct for it.