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es-hcm-classify-severity-sca

This skill categorizes hypercalcemia of malignancy (HCM) severity using albumin‑adjusted serum calcium into mild (<12 mg/dL), moderate (12‑14 mg/dL), or severe (>14 mg/dL). Use it when a clinician needs to stage HCM to guide initial therapy choices, such as deciding between observation, IV bisphosphonate/denosumab, or calcitonin‑based combination regimens.

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Classify HCM severity using albumin‑adjusted serum calcium

STEP 1 — Gather Information

Collect serum total calcium (mg/dL) and serum albumin (g/dL) from a recent blood draw; calculate albumin‑adjusted calcium using the formula: adjusted Ca = total Ca + 0.8 × (4 – albumin).
Proceed to calculate adjusted calcium.

STEP 2 — Rule In / Rule Out

Is albumin‑adjusted calcium <12 mg/dL?

  • If yes → classify as mild HCM and go to Step 4 for mild management.
  • If no → proceed to Step 3.

STEP 3 — Classify or Stratify

If albumin‑adjusted calcium is 12‑14 mg/dL → moderate HCM; if >14 mg/dL → severe HCM.
Proceed to Step 4 for severity‑specific management.

STEP 4 — Decide

For mild HCM, consider observation or oral agents (e.g., calcimimetics) if symptomatic; for moderate HCM, initiate IV bisphosphonate (e.g., zoledronic acid 4 mg) or denosumab 120 mg SC; for severe HCM, start combination therapy with IV calcitonin (4‑8 units/kg every 6‑12 h for 48‑72 h) plus IV bisphosphonate or denosumab.
Implement the selected regimen and reassess calcium within 24‑48 h.

Clinical Guardrails / Mimics / Pitfalls

Do not rely on total calcium alone in hypoalbuminemic patients; avoid using ionized calcium without adjustment unless validated; ensure albumin measurement is contemporaneous; do not delay therapy while awaiting repeat labs in symptomatic severe HCM; avoid using calcitonin beyond 48‑72 h due to tachyphylaxis; do not use loop diuretics routinely; avoid NSAIDs that may worsen renal function.

Concrete Clinical Example

A 62‑year‑old woman with non‑small cell lung cancer presents with fatigue and polyuria. Labs: total calcium 11.2 mg/dL, albumin 2.8 g/dL. Adjusted calcium = 11.2 + 0.8×(4‑2.8) = 12.16 mg/dL → moderate HCM. She receives zoledronic acid 4 mg IV over 15 minutes. Calcium drops to 9.8 mg/dL at 24 h.

Source: Treatment of Hypercalcemia of Malignancy in Adults: An Endocrine Society Clinical Practice Guideline, Endocrine Society, 2023, https://doi.org/10.1210/clinem/dgac621

TODO: consider adding scripts/calc.py for the es-hcm-classify-severity-sca calculator

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