From the Guidelines
Management of hypercalcemia involves addressing the underlying cause while implementing measures to lower serum calcium levels, with a focus on avoiding hypercalcemia in patients with chronic kidney disease (CKD) G3a to G5D, as recommended by the Kidney Disease: Improving Global Outcomes 2017 clinical practice guideline update 1.
Key Management Strategies
- For mild hypercalcemia (calcium <12 mg/dL), initial management includes adequate hydration with intravenous normal saline at 200-300 mL/hour to promote calcium excretion, followed by loop diuretics like furosemide 20-40 mg IV every 12 hours once the patient is well-hydrated to enhance calcium elimination.
- For moderate to severe hypercalcemia (calcium >12 mg/dL), bisphosphonates are first-line therapy, with zoledronic acid 4 mg IV over 15 minutes being most effective, or pamidronate 60-90 mg IV over 2-4 hours as an alternative.
- Calcitonin can provide rapid but short-term calcium reduction at 4 IU/kg SC/IM every 12 hours.
- Non-calcium-based phosphate binders such as sevelamer (800-1600 mg with meals) or lanthanum carbonate (500-1000 mg with meals) are preferred in dialysis patients, as they can reduce intestinal calcium absorption without the potential harm associated with calcium-based phosphate binders 1.
Considerations for Phosphate Binders
- Decisions about phosphate-lowering treatment should be based on progressively or persistently elevated serum phosphate, rather than as a preventive measure in patients with normal phosphate levels 1.
- Restricting the dose of calcium-based phosphate binders is recommended, as excess exposure to calcium may be harmful across all GFR categories of CKD.
- Limiting dietary phosphate intake may be beneficial in the treatment of hyperphosphatemia, in addition to phosphate-lowering therapies.
Ongoing Management
- Monitoring serum calcium, phosphate, and renal function is crucial, with treatment adjustments based on response and addressing the underlying cause whenever possible.
- Cinacalcet (30-90 mg daily) is effective for hypercalcemia due to hyperparathyroidism, while denosumab 120 mg SC may be used for malignancy-related hypercalcemia resistant to bisphosphonates.
- Glucocorticoids like prednisone 40-60 mg daily can help in cases associated with granulomatous diseases or certain malignancies.
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 Patients who have hypercalcemia of malignancy can generally be divided into two groups, according to the pathophysiologic mechanism involved: humoral hypercalcemia and hypercalcemia due to tumor invasion of bone
The management strategies for hypercalcemia include:
- Reducing excessive bone resorption
- Maintaining adequate fluid administration
- Correcting volume deficits
- Addressing the underlying pathophysiologic mechanism, which can be either humoral hypercalcemia or hypercalcemia due to tumor invasion of bone
- The use of bisphosphonates, such as pamidronate disodium and zoledronic acid, which inhibit osteoclastic bone resorption 2, 3, 3 Note that phosphate binders are not directly mentioned in the provided drug labels as a management strategy for hypercalcemia.
From the Research
Management Strategies for Hypercalcemia
The management of hypercalcemia involves a range of strategies, including hydration, loop diuretics, calcitonin, bisphosphonates, and glucocorticoids 4, 5, 6, 7, 8.
- Hydration is the first step in treating hypercalcemia, with loop diuretics used to prevent fluid overload in individuals with renal insufficiency or heart failure 4, 5, 7, 8.
- Calcitonin is used for the immediate short-term management of severe symptomatic hypercalcemia, with bisphosphonates added for long-term control 4, 5, 6, 7, 8.
- Bisphosphonates, such as zoledronic acid or pamidronate, are the agents of choice for the treatment of hypercalcemia, with glucocorticoids effective in hypercalcemia due to lymphoma or granulomatous diseases 4, 5, 6, 7, 8.
Use of Calcium Binders (Phosphate Binders)
Phosphate binders are not typically used as a primary treatment for hypercalcemia, but may be used in certain cases to reduce intestinal calcium absorption 8.
- However, measures that seek to reduce intestinal calcium absorption are seldom effective, and phosphate binders are not commonly used in the management of hypercalcemia 8.
Treatment of Underlying Cause
The underlying cause of hypercalcemia should be identified and treated, with parathyroidectomy considered for primary hyperparathyroidism and anti-tumor therapy for malignancy-related hypercalcemia 4, 5, 6, 7.
- Definitive correction of the underlying cause is important in controlling chronic hypercalcemia, with medical therapy available to control bone sequelae in asymptomatic, mild hyperparathyroidism where surgery is not indicated 7.