From the Guidelines
Hypercalcemia management in an inpatient setting involves a multi-faceted approach. The primary goal is to lower serum calcium levels, and this can be achieved through hydration, bisphosphonates, denosumab, steroids, and/or calcitonin 1.
Treatment Options
- Bisphosphonates: Among the bisphosphonates, zoledronic acid is preferred for the treatment of hypercalcemia 1.
- Hydration: Hydration with normal saline is essential to enhance renal excretion of calcium.
- Loop Diuretics: Loop diuretics such as furosemide can be used to further enhance calcium excretion.
- Glucocorticoids: Glucocorticoids like prednisone may be considered in specific cases, such as vitamin D-mediated hypercalcemia or sarcoidosis.
Key Considerations
- Zoledronic Acid: The preferred bisphosphonate for hypercalcemia treatment, administered intravenously 1.
- Calcitonin: Can be used as an alternative, with a dose of 4-8 IU/kg every 12 hours, and a maximum dose of 400 IU per injection.
- Hydration and Diuretics: Essential for enhancing renal excretion of calcium, with normal saline administered at a rate of 200-300 mL/hour and furosemide 20-40 mg every 2-4 hours.
- Monitoring: Close monitoring of serum calcium levels, renal function, and potential side effects of treatment is crucial in the management of hypercalcemia in an inpatient setting 1.
From the FDA Drug Label
Reducing excessive bone resorption and maintaining adequate fluid administration are, therefore, essential to the management of hypercalcemia of malignancy Correction of excessive bone resorption and adequate fluid administration to correct volume deficits are therefore essential to the management of hypercalcemia Calcitonin-salmon injection is indicated for the early treatment of hypercalcemic emergencies, along with other appropriate agents, when a rapid decrease in serum calcium is required, until more specific treatment of the underlying disease can be accomplished
The management of hypercalcemia in an inpatient setting involves:
- Reducing excessive bone resorption
- Maintaining adequate fluid administration to correct volume deficits
- Using medications such as zoledronic acid, pamidronate, or calcitonin to decrease serum calcium levels
- Correcting underlying causes of hypercalcemia, such as malignancy
- Monitoring serum calcium levels and adjusting treatment as needed 2, 3, 4
From the Research
Management of Hypercalcemia
The management of hypercalcemia in an inpatient setting typically involves a combination of treatments, including:
- Intravenous fluid rehydration to help restore normal fluid balance and promote calcium excretion 5
- Furosemide diuresis to enhance calcium excretion in the urine 5
- Bisphosphonates, such as pamidronate, to reduce bone resorption and lower serum calcium levels 5, 6
- Calcitonin, which can be used in combination with pamidronate to hasten normalization of serum calcium levels 5
Treatment Options
Treatment options for hypercalcemia may vary depending on the underlying cause and severity of the condition. Some possible treatment options include:
- Pamidronate, which can be administered in doses of 30-90 mg intravenously, with a dose-response relationship observed for normalization of corrected serum calcium 6
- Gallium nitrate, which can be used as an alternative to pamidronate, although it may be less convenient 5
- Steroids, which may be reserved for hypercalcemia due to tumor production of 1,25 dihydroxyvitamin D or for steroid-responsive malignancies 5
- Oral or parenteral bisphosphonates, which can be used to maintain normocalcemia and reduce bone pain and pathological fractures in patients with bone metastases 5
Safety and Efficacy
The safety and efficacy of pamidronate in patients with hypercalcemia have been evaluated in several studies, including:
- A study that found pamidronate to be highly effective and well-tolerated in patients with hypercalcemia of malignancy, with a single-dose infusion of 60-90 mg normalizing corrected serum calcium in nearly all patients 6
- A study that found no evidence of renal toxicity in patients receiving pamidronate 90 mg infused over 60 minutes at weekly intervals 7
- A study that found pamidronate to be safe and effective in patients with underlying renal insufficiency, with hypercalcemia resolving or improving in 91% of patients 8
- A study that found the pharmacokinetics of pamidronate disodium to be consistent with a biexponential process, with a linear relationship between amount of drug excreted in urine and dose 9