Endocrine Abstracts

Introduction: We conducted a retrospective audit of emergency management of hypercalcaemia presenting to the acute medical team and compared our practice against the Society for Endocrinology guidelines September 2016.

Method: 53 adult patients with 59 corresponding medical admissions were identified from tracking all biochemistry samples with corrected calcium (cCa) ≥3.0 mmol/l processed between August 2015 and July 2016 trustwide. We conducted a retrospective review of their admissions’ case records.

Results: Characteristics: age 40–98 years old (median 79), 60.4% female, median length of stay 7 days, presenting cCa range: 3.04–5.36 mmol/l (median 3.31 mmol/l). 30.5% had severe hypercalcaemia (cCa ≥3.50 mmol/l). Aetiology: 47.2% malignancy related hypercalcaemia, 15.1% primary hyperparathyroidism, 5.6% secondary or tertiary hyperparathyroidism, 9.4% drug-related, 15.1% unknown. Frailty was documented reason to withdraw further investigations in 62.5% of the latter. Coexistent active prostate cancer and hyperparathyroidism was found in two cases. Investigations: PTH was checked in 67.8% cases, Phosphate in 64.4%, ALKP 100%. Of the cases with suppressed PTH, only 72.2% had serum paraproteins checked, 55.5% urinary Bence-Jones proteins and 83.3% imaging for malignancy. Vitamin D was only checked in 22.6%. Management: Patients received an average of 3L intravenous fluids in the first 24 h. 62.7% received intravenous bisphosphonates. 13.5% had less than 2L intravenous fluids prior to bisphosphonate. Second line treatment with Cinacalcet, steroids, Furosemide or Calcitonin was used in 20.7% cases. There were no cases of rebound hypocalcaemia.

Conclusions: Compliance with guidelines recommendations was suboptimal in certain areas, not entirely explained by the adoption of a palliative approach with focus on symptom control in cases. Training opportunities will be devised locally to improve practice. Bisphosphonate use in the Emergency department should be controlled for the appropriate circumstances. Vigilance is recommended assigning causality in active malignancy, given that 11.1% of pre-existing malignancy cases were found to have concurrent PTH driven hypercalcaemia, despite only 38.9% of them being investigated with a PTH level.