Cause, severity and the presence of symptoms guide the treatment of hypocalcemia. Mild to moderate cases of hypocalcemia can be treated by giving oral calcium and vitamin D supplements but in severe cases intravenous (IV) calcium gluconate is preferred. Most of the hypocalcemic cases are mild and require only supportive treatment and laboratory evaluation.

• Pharmacologic medical therapies for hypocalcemia include calcium, vitamin D , calcium gluconate^[1][2][3]
• Patients who present with asymptomatic hypocalcemia, it is important to repeat the levels of ionized calcium and confirm it.

• Patients who present with hypocalcemia, intravenous (IV) calcium therapy is recomended, especially in patients who exhibit the following features^[4]
  • Patients who have prolonged QT interval.
  • Patients who have serum corrected calcium of ≤7.5 mg/dL.
  • Patients who are positive for clinical symptoms such as carpopedal spasm, tetany, seizures.

• Patients who are presenting with milder symptoms of neuromuscular irritability like paresthesias and corrected calcium levels more than 7.5 mg/dL treating with oral calcium and vitamin D supplements is of first choice.
• Patients with milder hypocalcemia who are on the oral supplements and shows no sign of improvement the next best best step in treating would be switching to IV calcium.
• And patients who are requiring intravenous (IV) repletion should be admitted.
  • Preferred regimen (1): Elemental calcium 1-3 g/d.

• IV calcium is recommended for patients who shows symptoms of severe hypocalcemia like the following^[5][6]
  • Carpopedal spasm
  • Tetany
  • Seizures
  • QT interval prolongation

• IV calcium is recommended for asymptomatic patients whose serum corrected calcium levels are ≤7.5 mg/dL.
• If left untreated asymptomatic patients may end up with serious complications.
• Following post-radical neck dissection patients may end up with acute hypoparathyroidism which leads to acute hypocalcemia due to rapid reduction in serum calcium^[7][8]
  • Preferred regimen (1): IV calcium gluconate 1 or 2 g in 50 mL of 5 percent dextrose or normal saline given over 10 to 20 minutes.
  • Due to risk of serious cardiac dysfunction, calcium should be given slowly.

• Following should be considered while preparing the IV calcium infusion
  • Calcium should be diluted in dextrose or water because concentrated calcium is an irritant to veins.
  • IV infusion should not contain bicarbonate or phosphate.

• Until the patient receives oral calcium and vitamin D, IV calcium should be continued.

• When serum corrected calcium levels are between 7.5 to 8.0 mg/dL are considered as mild hypocalcemia.^[9]
• Oral calcium supplementation is preferred for the patients who are presenting with mild or chronic hypokalemia.
  • Preferred regimen (1): Elemental calcium( calcium carbonate or calcium citrate) 500 to 2000 mg in divided doses.

Hypocalcemia is considered an absolute contraindication to the use of the following medications:

• Alendronate
• Ibandronic acid
• Cinacalcet
• Denosumab