What are the recommended management strategies for a patient with asymptomatic hypercalcaemia?

For a patient with asymptomatic hypercalcaemia, the recommended management strategies include:

• Initial assessment and investigation: Perform a full clinical assessment and arrange initial investigations to establish the probable cause of hypercalcaemia, including measuring albumin-adjusted serum calcium and parathyroid hormone (PTH) levels if indicated. Repeat calcium measurement at least once to confirm persistence ¹,².
• Review and modify medications: Review medications that may exacerbate hypercalcaemia, such as thiazide diuretics, lithium, calcium, and vitamin D supplements, and consider stopping them if appropriate ¹.
• Referral to specialist: Refer to an appropriate specialist (e.g., endocrinologist) unless a reversible cause is identified and corrected with normalization of calcium levels. Referral urgency depends on calcium level severity and clinical context ¹,².
• Monitoring: Arrange monitoring of calcium levels and clinical condition in primary care, with repeat calcium testing at least 3 weeks after any medication changes. Advise maintaining adequate oral hydration ¹.
• Management of primary hyperparathyroidism: If primary hyperparathyroidism is suspected (e.g., raised calcium with raised or inappropriately normal PTH), refer to an endocrinologist for further diagnostic workup and management, including consideration of surgery even if asymptomatic ¹,².
• Non-surgical management: For those unsuitable for surgery or who decline it, consider medical options such as cinacalcet or bisphosphonates based on calcium levels and fracture risk, under specialist guidance ².

In summary, asymptomatic hypercalcaemia requires careful evaluation to identify the cause, modification of contributing factors, specialist referral for diagnosis and management, and ongoing monitoring in primary care ¹,².