Intended for healthcare professionals

Clinical Review

The diagnosis and management of hypercalcaemia

BMJ 2015; 350 doi: (Published 02 June 2015) Cite this as: BMJ 2015;350:h2723
  1. Salvatore Minisola, professor,
  2. Jessica Pepe, consultant,
  3. Sara Piemonte, consultant,
  4. Cristiana Cipriani, consultant
  1. 1Department of Internal Medicine and Medical Disciplines, “Sapienza” Rome University, 00161 Rome, Italy
  1. Correspondence to: S Minisola salvatore.minisola{at}

The bottom line

  • Primary hyperparathyroidism and malignancy are the two most common causes of increased serum calcium levels

  • The diagnosis of hypercalcaemia is made when the corrected serum calcium concentration is 2 standard deviations above the mean of values found in people with normal calcium levels, in at least two samples at least one week apart over a period of three months

  • The presence of high or not adequately suppressed serum parathyroid hormone levels should point the diagnosis towards hypercalcaemia of parathyroid origins

  • Mild hypercalcaemia is usually caused by primary hyperparathyroidism, the treatment for which is typically surgery; those aged 50 or more with serum calcium levels <0.25 mmol/L above the upper limit of normal and without end organ damage may be followed up conservatively. Treatment with a calcimimetic agent, cinacalcet, is an option in selected cases

  • Severe hypercalcaemia requires admission to hospital and treatment with aggressive intravenous hydration and bisphosphonates along with treatment of the underlying disease

Hypercalcaemia is a common finding in the setting of primary care,1 as well as in emergency departments2 and patients admitted to hospital.3 Primary hyperparathyroidism and malignancy are the two most common causes of increased serum calcium levels, together accounting for about 90% of all cases.4 The remaining 10% represent an important figure, and thus the need to consider other disorders in the evaluation of patients with hypercalcaemia. This review aims to give an overview of the diagnosis and clinical management of hypercalcaemia for non-specialist clinicians and health professionals.

Sources and selection criteria

We carried out a search through Medline and PubMed of articles published from 1990 to 2015 using the terms “mild hypercalcaemia” and “severe “hypercalcemia”, “primary hyperparathyroidism”, “hypercalcemia of malignancy”, “parathyroid hormone measurement”, “parathyroidectomy”, and “cinacalcet” and through the National Cancer Institute using the term “hypercalcaemia”. We also retrieved personal archived references to identify …

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