GPAtlas🧭 When to suspect
Hypercalcaemia is an albumin-adjusted (corrected) serum calcium above the upper reference limit – typically > 2.60 mmol/L, though local laboratory ranges vary.
It is common, and over 90% of cases are explained by just two conditions:
• Primary hyperparathyroidism (PHPT) – usually mild, often incidental, in an otherwise well outpatient.
• Malignancy – typically a sicker patient with a higher calcium.
The classic syndrome is “stones, bones, abdominal moans and psychic groans”: renal stones, bone pain, abdominal pain with constipation and nausea, thirst and polyuria, and cognitive change.
In practice, the commonest presentation is now an incidental finding on a routine biochemical screen.
Two questions drive everything: how high and how unwell the patient is (severity sets urgency), and what the parathyroid hormone (PTH) is doing (PTH points to the cause).
| Adjusted calcium | Severity | Action |
|---|---|---|
| 2.20–2.60 mmol/L | Normal | Within reference range (local labs vary) – no action |
| 2.60–3.00 mmol/L | Mild | • Often asymptomatic • Confirm, review medication, measure PTH – usually a primary-care work-up |
| 3.00–3.50 mmol/L | Moderate | • Prompt treatment usually needed • Same-day admission if symptomatic or dehydrated |
| > 3.50 mmol/L | Severe | • Emergency – risk of dysrhythmia and coma • Same-day admission for IV rehydration |
Beyond PHPT and malignancy (myeloma, breast, lung – especially squamous, renal), consider:
• Drugs (thiazide diuretics, lithium, calcium and vitamin D supplements, vitamin A).
• Granulomatous disease (sarcoidosis, tuberculosis).
• Thyrotoxicosis.
• Prolonged immobilisation.
• Adrenal insufficiency.
• Milk-alkali syndrome.
• Familial hypocalciuric hypercalcaemia (FHH).
Source: Society for Endocrinology · NICE NG132
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