HWN Suggests

Milk-Alkali Syndrome: A Forgotten Cause of Metabolic Alkalosis

The most common causes of hypercalcemia are hyperparathyroidism and malignancy. MAS is now considered the third most common cause of hypercalcemia with a prevalence of 9% to 12% among hospitalized patients. With the development of non-absorbable alkali and histamine 2 blockers for treatment of peptic ulcer disease, MAS became a rare cause of hypercalcemia; however, with the increased use of over the counter calcium carbonate for dyspepsia and supplementation, there is a revival of MAS. In the era of introduction of antacids, MAS was common in patients with peptic ulcer disease. However, modern era calcium-alkali syndrome is now more common in postmenopausal women, pregnant women, transplant…

read full article

Featured

 Antacids, Altered Mental Status, and Milk-Alkali Syndrome

Milk-alkali syndrome can be a difficult diagnosis that requires a high index of suspicion in order to quickly identify the disorder and initiate appropriate therapy. As a common cause of hypercalcemia, it is important for clinicians to keep the syndrome on their list of differential diagnoses.

Articles of Interest

A Case of Milk-Alkali Syndrome

Milk-alkali syndrome is described by a triad of elevated levels of calcium, metabolic alkalosis, and acute kidney injury that historically occurred as a result of the combined intake of large amounts of calcium and absorbable alkali. It is becoming common recently with the use of over-the-counter calcium supplements for osteoporosis treatment in postmenopausal women

Calcium Carbonate Intoxication in Pregnancy: The Return of the Milk-Alkali Syndrome

CAS should be considered in the differential diagnosis of hypercalcemia in pregnancy, especially when there is renal failure without an obvious cause.

Calcium-Alkali Syndrome in the Modern Era

The ingestion of calcium, along with alkali, results in a well-described triad of hypercalcemia, metabolic alkalosis, and renal insufficiency. Over time, the epidemiology and root cause of the syndrome have shifted, such that the disorder, originally called the milk-alkali syndrome, is now better described as the calcium-alkali syndrome.

Life-threatening milk-alkali syndrome resulting from antacid ingestion during pregnancy

Oral calcium carbonate is now the predominant source of calcium and alkali associated with the development of milk-alkali syndrome (with or without milk intake). The amount of calcium carbonate required to be ingested per day to cause milk-alkali syndrome is reported to vary from as low as 4 g to as high as 60 g.

Milk Alkali Syndrome and the Dynamics of Calcium Homeostasis

Intensive treatment with calcium-containing antacids and milk first was used in the early 20th century for the treatment of peptic ulcer disease and sometimes was associated with toxicity, eventually known as the milk alkali syndrome. Despite the introduction of H2 blockers and proton pump inhibitors for the treatment of peptic ulcer disease, the milk alkali syndrome continues to occur but is seen more frequently in older women who are receiving treatment for osteoporosis.

Milk-Alkali Syndrome

Milk-alkali syndrome (MAS) consists of hypercalcemia, various degrees of renal failure, and metabolic alkalosis due to ingestion of large amounts of calcium and absorbable alkali. This syndrome was first identified after medical treatment of peptic ulcer disease with milk and alkali was widely adopted at the beginning of the 20th century. With the introduction of histamine2 blockers and proton pump inhibitors, the occurrence of MAS became rare; however, a resurgence of MAS has been witnessed because of the wide availability and increasing use of calcium carbonate, mostly for osteoporosis prevention.

Milk-alkali syndrome: a ‘quick ease’ or a ‘long-lasting problem’

Milk-alkali syndrome is an often unrecognised cause for hypercalcaemia, but is the third most common cause of admission for hypercalcaemia. The effect of over-the-counter calcium supplementation on the development of hypercalcaemia should not be underestimated.

The Milk-Alkali Syndrome A Reversible Form of Acute Renal Failure

The milk-alkali syndrome became rare with the advent of modern ulcer therapy with nonabsorbable antacids, histamine2 blockers, and sucralfate. An increased frequency of this syndrome seems likely with the growing popularity of the use of calcium carbonate as an antacid or as calcium supplementation to prevent osteoporosis.

Resources

Mayo Clinic Proceedings

With the introduction of histamine2 blockers and proton pump inhibitors, the occurrence of MAS became rare; however, a resurgence of MAS has been witnessed because of the wide availability and increasing use of calcium carbonate, mostly for osteoporosis prevention.

StatPearls

Milk-alkali syndrome manifests through the triad of symptoms of elevated calcium levels, metabolic alkalosis, and acute kidney injury. Historically associated with the consumption of large quantities of milk and bicarbonate for peptic ulcer treatment, the syndrome is now predominantly triggered by excessive intake of calcium carbonate, particularly among osteoporosis patients or those with chronic kidney disease.