Dr Kola Tytler MBBS CertHE MBA MRCGPClinical Lead • iatroX
Indications for referral to secondary care for a patient presenting with hypercalcaemia include:
- Severe hypercalcaemia (corrected calcium >3.5 mmol/L) or severe symptoms: arrange emergency hospital admission for specialist assessment and management such as intravenous fluids and bisphosphonate therapy NICE CKS.
- Moderate hypercalcaemia (corrected calcium 3.0–3.5 mmol/L) or symptomatic patients: consider immediate same-day referral to hospital or liaise with an appropriate specialist depending on clinical picture NICE CKS.
- Mild hypercalcaemia (corrected calcium >2.6 but <3.0 mmol/L) if asymptomatic but persistent after correction of reversible causes, or if primary hyperparathyroidism is suspected (e.g., raised PTH): refer to an endocrinologist for further investigation and management NICE CKS.
- Known or suspected malignancy-associated hypercalcaemia: refer urgently via local cancer pathways or liaise with oncologist/palliative care specialist for management, especially if hypercalcaemia is moderate or severe NICE CKS.
- Features suggestive of primary hyperparathyroidism requiring surgical consideration, including symptoms of hypercalcaemia, end-organ damage (renal stones, fragility fractures, osteoporosis), or albumin-adjusted serum calcium ≥2.85 mmol/L: refer to a surgeon with expertise in parathyroid surgery NICE NG132.
- Unexplained hypercalcaemia after initial investigations in primary care: refer to an appropriate specialist (e.g., endocrinologist) for further assessment NICE CKS.
Additional considerations: If the patient is on medications that may cause hypercalcaemia (e.g., thiazides, lithium), consider stopping and rechecking calcium before referral unless calcium remains elevated NICE CKS. Liaise with mental health specialists if lithium is involved NICE CKS.