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Contributors: Peter Joo MD, Abhijeet Waghray MD, Paritosh Prasad MD, Eric Ingerowski MD, FAAP
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Hypercalcemia is elevated serum calcium concentration and is most commonly caused by drugs, malignancy, and primary hyperparathyroidism. Patients present with stones (renal or biliary), bones (bone pain), abdominal moans (abdominal pain, nausea, and vomiting), and psychic groans (decreased concentration, confusion, fatigue, stupor, and coma). Cardiovascular consequences can also ensue, manifesting as cardiac arrhythmias due to a truncated QT interval.

Drug-induced hypercalcemia can be due to excessive drug consumption (vitamin A, vitamin D, or thiazide diuretics). Calcium absorption (or bone resorption) exceeds the excretion of calcium, resulting in excess calcium in the blood. Less commonly associated medications include lithium (due to increased secretion of parathyroid hormone [PTH]), teriparatide, theophylline (mild toxicity via beta-adrenergic regulation), and certain topical ointments.

Non-drug-induced causes are parathyroid disorders, specific malignancies such as solid tumors (commonly lung, breast, ovarian, kidney, and pancreatic primary tumors), carcinomas with or without bone metastases, hematologic cancers (leukemia, lymphoma, myeloma, etc), granulomatous diseases (sarcoidosis, tuberculosis, granulomatosis with polyangiitis, histoplasmosis, coccidioidomycosis, silicosis, berylliosis, Pneumocystis pneumonia, and Nocardia infection), chronic liver disease, renal insufficiency, kidney transplant, bacteriosis, parenteral feeding, and familial hypocalciuric hypercalcemia.

Cancer-associated hypercalcemia may be caused by elevated levels of PTH, PTH-related protein, 1,25-dihydroxyvitamin D, tumor necrosis factor (TNF), interleukin (IL)-6, IL-1, macrophage inhibitory protein, and other mediators. Cancer-associated hypercalcemia has a poor prognosis.

Rare causes include dehydration, pheochromocytoma, acute adrenal insufficiency, Paget disease, Williams syndrome, and prolonged immobilization.


E83.52 – Hypercalcemia

66931009 – Hypercalcemia

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Diagnostic Pearls

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Differential Diagnosis & Pitfalls

Causes of hypercalcemia:
  • Primary hyperparathyroidism – PTH will be elevated in primary hyperparathyroidism and should be low in drug-induced hypercalcemia (except in lithium use).
  • Tertiary hyperparathyroidism (Chronic kidney disease)
  • Malignancy – May have elevated PTH-related protein, elevated 1,25-dihydroxyvitamin D, or evidence of bony metastases.
  • Hyperthyroidism
  • Pheochromocytoma
  • Immobility (increased bone calcium reabsorption)
  • Oversupplementation (eg, Milk-alkali syndrome, parenteral nutrition)
  • Familial hypocalciuric hypercalcemia (genetic)
  • Sarcoidosis
  • Tuberculosis
  • Dehydration – Transient rise in serum calcium.
  • Vitamin D intoxication
  • Medications (eg, lithium, theophylline, teriparatide, thiazide diuretics)
  • Adrenal insufficiency (Addison disease and Secondary adrenal insufficiency)

Best Tests

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Management Pearls

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Drug Reaction Data

Below is a list of drugs with literature evidence indicating an adverse association with this diagnosis. The list is continually updated through ongoing research and new medication approvals. Click on Citations to sort by number of citations or click on Medication to sort the medications alphabetically.

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Last Reviewed:07/25/2019
Last Updated:05/04/2022
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A medical illustration showing key findings of Hypercalcemia (Moderate) : Abdominal pain, Headache, Nausea/vomiting, Constipation, Malaise, Polyuria, Anorexia, Polydipsia, Ca elevated
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