5-Minute Clinical Consult
Milk-Alkali Syndrome
Basics
Description
- 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 of indigestion or reflux (heartburn)
- Also seen with treatment/prevention of postmenopausal osteoporosis, consumption of carbonated beverages and calcium salts
- Characterized by:
- Hypercalcemia
- Metabolic alkalosis
- ± Renal insufficiency
- System(s) affected: endocrine/metabolic; gastrointestinal (GI); renal/urologic
- Synonym(s): Burnett syndrome; Cope syndrome; milk poisoning; milk drinker syndrome; calcium alkali syndrome
Epidemiology
Incidence
- Third most common cause of hypercalcemia
- Recent increase associated with treatment for prevention of osteoporosis
Prevalence
Infrequent in the outpatient setting but 9–12% among hospitalized patients who have hypercalcemia
Etiology and Pathophysiology
- Cyclic process between intestines and kidneys: hypercalcemia from high-calcium intake (usually >4 g/day) believed secondary to inadequate response to calcitriol
- Hypercalcemia leads to vasoconstriction ultimately decreasing glomerular filtration.
- Activation of calcium-sensing receptors increases calcium reabsorption, absorption of bicarbonate, and natriuresis (maintaining alkalotic state).
- Blockade of antidiuretic hormone leads to increased diuresis.
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 women (more common overall in women)
- Nicotine substitute chewing gum in large quantities
General Prevention
- Avoid excess milk and/or absorbable antacids.
- Use noncarbonate salts for calcium supplementation.
- Caution in elderly treated with ACE-I/ARB, NSAIDs, and diuretic
Commonly Associated Conditions
- Peptic ulcer disease
- Hiatal hernia
- Gastroesophageal reflux
- Osteoporosis
- Hypertension
- Hyperparathyroidism
- Hypercalcemia of malignancy
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Citation
Domino, Frank J., et al., editors. "Milk-Alkali Syndrome." 5-Minute Clinical Consult, 34th ed., Wolters Kluwer, 2026. Medicine Central, im.unboundmedicine.com/medicine/view/5-Minute-Clinical-Consult/1688815/all/Milk_Alkali_Syndrome.
Milk-Alkali Syndrome. In: Domino FJF, Baldor RAR, Golding JJ, et al, eds. 5-Minute Clinical Consult. Wolters Kluwer; 2026. https://im.unboundmedicine.com/medicine/view/5-Minute-Clinical-Consult/1688815/all/Milk_Alkali_Syndrome. Accessed November 4, 2025.
Milk-Alkali Syndrome. (2026). In Domino, F. J., Baldor, R. A., Golding, J., & Stephens, M. B. (Eds.), 5-Minute Clinical Consult (34th ed.). Wolters Kluwer. https://im.unboundmedicine.com/medicine/view/5-Minute-Clinical-Consult/1688815/all/Milk_Alkali_Syndrome
Milk-Alkali Syndrome [Internet]. In: Domino FJF, Baldor RAR, Golding JJ, Stephens MBM, editors. 5-Minute Clinical Consult. Wolters Kluwer; 2026. [cited 2025 November 04]. Available from: https://im.unboundmedicine.com/medicine/view/5-Minute-Clinical-Consult/1688815/all/Milk_Alkali_Syndrome.
* Article titles in AMA citation format should be in sentence-case
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T1 - Milk-Alkali Syndrome
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ED - Golding,Jeremy,
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UR - https://im.unboundmedicine.com/medicine/view/5-Minute-Clinical-Consult/1688815/all/Milk_Alkali_Syndrome
PB - Wolters Kluwer
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