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Milk-Alkali Syndrome

Milk-Alkali Syndrome is a topic covered in the 5-Minute Clinical Consult.

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  • Milk-alkali syndrome results from ingestion of excessive amounts of calcium and absorbable alkali (e.g., bicarbonate and citrate salts).
  • Historically seen during self-treatment for indigestion or “heartburn”
  • Also seen with treatment/prevention of postmenopausal osteoporosis, consumption of carbonated beverages and calcium salts
  • Characterized by the following:
    • Hypercalcemia
    • Metabolic alkalosis
      • ± Renal insufficiency
  • System(s) affected: endocrine/metabolic; gastrointestinal; renal/urologic
  • Synonym(s): Burnett syndrome; Cope syndrome; milk poisoning; milk drinker syndrome; calcium-alkali syndrome


  • Third most common cause of hypercalcemia
  • Recent increase associated with treatment for prevention of osteoporosis

Infrequent in the outpatient setting but 9–12% among hospitalized patients who have hypercalcemia

General Prevention

  • Avoid excess milk and/or absorbable antacids.
  • Use noncarbonate salts for calcium supplementation.

Etiology and Pathophysiology

  • Cyclic process between intestines and kidneys: hypercalcemia from high-calcium intake (usually >4 g/day) coupled with increased renal calcium reabsorption due to metabolic alkalosis (by sensitizing calcium-sensing receptor in the kidney)
  • Hypercalcemia leads to suppression of parathyroid hormone–reduced urinary calcium excretion (by inducing volume depletion). An increase in the reabsorption of bicarbonate also maintains the metabolic alkalosis.

Risk Factors

  • Use of calcium-containing antacids or supplements
  • Chronic kidney disease
  • Simultaneous vitamin D supplementation
  • Thiazide diuretic therapy
  • Pregnancy (increased GI calcium absorption)
  • Elderly
  • Postmenopausal woman
  • More common in women than men

Commonly Associated Conditions

  • Peptic ulcer disease
  • Gastroesophageal reflux
  • Hiatal hernia
  • Osteoporosis
  • Hypertension
  • Hyperparathyroidism
  • Hypercalcemia of malignancy

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Stephens, Mark B., et al., editors. "Milk-Alkali Syndrome." 5-Minute Clinical Consult, 27th ed., Wolters Kluwer, 2019. Medicine Central, im.unboundmedicine.com/medicine/view/5-Minute-Clinical-Consult/116384/all/Milk_Alkali_Syndrome.
Milk-Alkali Syndrome. In: Stephens MB, Golding J, Baldor RA, et al, eds. 5-Minute Clinical Consult. 27th ed. Wolters Kluwer; 2019. https://im.unboundmedicine.com/medicine/view/5-Minute-Clinical-Consult/116384/all/Milk_Alkali_Syndrome. Accessed April 26, 2019.
Milk-Alkali Syndrome. (2019). In Stephens, M. B., Golding, J., Baldor, R. A., & Domino, F. J. (Eds.), 5-Minute Clinical Consult. Available from https://im.unboundmedicine.com/medicine/view/5-Minute-Clinical-Consult/116384/all/Milk_Alkali_Syndrome
Milk-Alkali Syndrome [Internet]. In: Stephens MB, Golding J, Baldor RA, Domino FJ, editors. 5-Minute Clinical Consult. Wolters Kluwer; 2019. [cited 2019 April 26]. Available from: https://im.unboundmedicine.com/medicine/view/5-Minute-Clinical-Consult/116384/all/Milk_Alkali_Syndrome.
* Article titles in AMA citation format should be in sentence-case
TY - ELEC T1 - Milk-Alkali Syndrome ID - 116384 ED - Stephens,Mark B, ED - Golding,Jeremy, ED - Baldor,Robert A, ED - Domino,Frank J, BT - 5-Minute Clinical Consult, Updating UR - https://im.unboundmedicine.com/medicine/view/5-Minute-Clinical-Consult/116384/all/Milk_Alkali_Syndrome PB - Wolters Kluwer ET - 27 DB - Medicine Central DP - Unbound Medicine ER -