From the Guidelines
The use of calcitonin is not the primary treatment for hypercalcemia of malignancy, but it can be considered as an adjunctive therapy to provide rapid, short-term calcium reduction while waiting for bisphosphonates to take effect, as recommended by the NCCN Guidelines for MM 1. The recommended treatment for hypercalcemia of malignancy includes aggressive intravenous hydration with normal saline, followed by bisphosphonates as the mainstay therapy.
- Initial management should begin with fluid resuscitation at 200-300 mL/hour to restore intravascular volume and enhance renal calcium excretion.
- Zoledronic acid (4 mg IV over 15 minutes) or pamidronate (60-90 mg IV over 2-4 hours) are the preferred bisphosphonates, with zoledronic acid showing greater efficacy, as noted in the study by Zervas et al 1.
- For severe or refractory cases, denosumab (120 mg SC weekly for 4 weeks, then monthly) may be used, especially in patients with renal impairment where bisphosphonates are contraindicated, as recommended by the NCCN MM Panel 1.
- Glucocorticoids can be added for certain malignancies (lymphoma, multiple myeloma).
- Loop diuretics should only be used after adequate hydration is achieved.
- Hemodialysis may be necessary in life-threatening hypercalcemia with renal failure. The underlying mechanism of hypercalcemia in malignancy typically involves tumor production of parathyroid hormone-related protein (PTHrP), direct bone destruction by metastases, or tumor-produced 1,25-dihydroxyvitamin D, which these treatments counteract while the primary malignancy is addressed, as described in the American College of Chest Physicians evidence-based clinical practice guidelines 1.
From the FDA Drug Label
The FDA drug label does not answer the question.
From the Research
Treatment of Hypercalcemia of Malignancy
The treatment of hypercalcemia of malignancy (HCM) involves several strategies, including:
- Aggressive hydration with 0.9% sodium chloride injection to encourage the normal bone remodeling process 2
- The use of bisphosphonates, such as pamidronate or zolendronic acid, to inhibit bone resorption 2, 3
- Denosumab, a monoclonal antibody against the receptor activator of nuclear factor κB ligand, for refractory disease 4
- Calcitonin, which is useful if a rapid decrease in serum calcium is necessary, but its use is limited by tachyphylaxis 2, 3, 5, 6
- Corticosteroids, which should be used only in patients with tumors that produce 1,25-dihydroxycholecalciferol 2, 6
Use of Calcitonin
Calcitonin is used in the treatment of HCM, particularly in cases with severe symptomatic hypercalcemia 3, 5, 6. However, its effectiveness is limited by tachyphylaxis, which develops after a few days of treatment 2, 3.
Recommended Treatment Approach
The recommended treatment approach for HCM involves:
- Treating the underlying malignancy, which is the most effective strategy 2
- Using a combination of hydration, bisphosphonates, and other therapies, such as calcitonin and corticosteroids, to manage symptoms and lower serum calcium levels 2, 3, 5, 4, 6
- Monitoring patients closely for potential adverse effects and adjusting treatment as needed 5, 4