From the Guidelines
Treatment for a calcium level of 13 mg/dL requires immediate medical attention with aggressive intravenous fluid rehydration and medications like bisphosphonates, specifically zoledronic acid, to inhibit bone resorption and reduce calcium levels. The management of hypercalcemia involves a multifaceted approach, including hydration, bisphosphonates, denosumab, steroids, and/or calcitonin, as recommended by the NCCN MM Panel members 1.
Key Considerations
- Aggressive intravenous fluid rehydration with normal saline at 200-300 mL/hour to increase calcium excretion through the kidneys
- Bisphosphonates, such as zoledronic acid 4 mg IV, to inhibit bone resorption, with effects beginning within 2-3 days
- Calcitonin (4 IU/kg subcutaneously every 12 hours) may be added for rapid but short-term calcium reduction
- Loop diuretics like furosemide (20-40 mg IV) can be used after adequate hydration is achieved
- Identification and treatment of the underlying cause of hypercalcemia, such as hyperparathyroidism or malignancy
- Discontinuation of calcium supplements, vitamin D, and medications that can raise calcium levels
- Monitoring of symptoms like confusion, weakness, constipation, and cardiac abnormalities
Additional Recommendations
- Plasmapheresis should be used as adjunctive therapy for symptomatic hyperviscosity 1
- Erythropoietin therapy may be considered for anemic patients, especially those with renal failure 1
- Prophylactic anti-coagulation agents are recommended when IMiDs are used in combination therapy during induction 1
- Intravenous immunoglobulin therapy should be considered for recurrent, life-threatening infections 1
- Pneumocystis jiroveci pneumonia, herpes zoster, and antifungal prophylaxis is recommended if high-dose dexamethasone is used 1
From the FDA Drug Label
The recommended dose of pamidronate disodium in severe hypercalcemia (corrected serum calcium* >13.5 mg/dL) is 90 mg given as a SINGLE-DOSE, intravenous infusion over 2 to 24 hours. The treatment for a calcium level of 13 is pamidronate disodium 90 mg as a single-dose intravenous infusion over 2 to 24 hours 2.
- Key points:
- Dose: 90 mg
- Administration: single-dose intravenous infusion
- Duration: 2 to 24 hours
- Indication: severe hypercalcemia (corrected serum calcium >13.5 mg/dL)
From the Research
Treatment for Calcium of 13
- The treatment for hypercalcemia, which is characterized by elevated calcium levels in the blood, typically starts with hydration 3, 4, 5.
- Loop diuretics may be required in individuals with renal insufficiency or heart failure to prevent fluid overload 3.
- Calcitonin is administered for the immediate short-term management of severe symptomatic hypercalcemia 3.
- For long-term control of severe or symptomatic hypercalcemia, the addition of bisphosphonate is typically required 3, 4, 5.
- Among intravenous bisphosphonates, zoledronic acid or pamidronate are the agents of choice 3, 4, 5.
- Glucocorticoids are effective in hypercalcemia due to lymphoma or granulomatous diseases 3, 4.
- Dialysis is generally reserved for those with severe hypercalcemia complicated with kidney failure 3, 4.
Specific Treatment Approaches
- For severe hypercalcaemia secondary to primary hyperparathyroidism, saline hydration, and zoledronic acid have been shown to be effective 5.
- Furosemide is not recommended for the treatment of hypercalcemia, as its effectiveness has not been proven and it may not provide additional benefits compared to saline hydration alone 5, 6.
- The use of furosemide in the management of hypercalcemia should no longer be recommended 6.
Additional Considerations
- It is essential to identify and treat the underlying cause of hypercalcemia 3, 4.
- The prognosis for asymptomatic primary hyperparathyroidism is excellent with either medical or surgical management, while hypercalcemia of malignancy is associated with poor survival 4.
- Drug-related hypercalcemia can occur due to various medications, including vitamin D supplements, thiazide diuretics, and lithium, and requires optimal medical management 7.