What is the treatment for hypercalcemia?

From the Guidelines

Treatment for hypercalcemia should prioritize addressing the underlying cause while lowering calcium levels, with bisphosphonates, such as zoledronic acid, being the first-line medication for severe hypercalcemia, as recommended by the most recent guidelines 1. The approach to treating hypercalcemia involves several key steps, including:

• Adequate hydration with intravenous normal saline to increase calcium excretion
• Use of loop diuretics like furosemide to enhance calcium elimination after adequate hydration
• Administration of bisphosphonates, with zoledronic acid 4 mg IV over 15 minutes being a preferred option for severe hypercalcemia, as it is effective in controlling hypercalcemia and reversing delirium in a substantial number of cases 1
• Consideration of calcitonin for rapid but temporary relief, and denosumab for refractory cases
• Tailoring treatment to the underlying cause, including parathyroidectomy for primary hyperparathyroidism and cancer-directed therapy for malignancy-related hypercalcemia Some key points to consider in the treatment of hypercalcemia include:
• The importance of ongoing monitoring of calcium, phosphate, and renal function during treatment
• The potential for denosumab to cause hypocalcaemia, and the need for monitoring and supplementation with calcium and vitamin D as necessary 1
• The preference for zoledronic acid over other bisphosphonates, such as pamidronate and ibandronate, due to its efficacy and safety profile 1
• The role of hydration and bisphosphonates in treating hypercalcemia, as well as the potential for other medications, such as steroids and calcitonin, to be used in certain cases 1

From the FDA Drug Label

1. 2 Treatment 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 It may also be added to existing therapeutic regimens for hypercalcemia such as intravenous fluids and furosemide, oral phosphate or corticosteroids, or other agents.
2. 2 Hypercalcemia The recommended starting dose of calcitonin-salmon injection for early treatment of hypercalcemia is 4 International Units/kg body weight every 12 hours by subcutaneous or intramuscular injection. If the response to this dose is not satisfactory after one or two days, the dose may be increased to 8 International Units/kg every 12 hours If the response remains unsatisfactory after two more days, the dose may be further increased to a maximum of 8 International Units/kg every 6 hours.

The treatment for hypercalcemia includes calcitonin-salmon injection as an early treatment option, often used in conjunction with other agents such as:

• Intravenous fluids
• Furosemide
• Oral phosphate
• Corticosteroids The recommended starting dose of calcitonin-salmon injection is 4 International Units/kg body weight every 12 hours, with possible dose increases to 8 International Units/kg every 12 hours or 8 International Units/kg every 6 hours if the initial response is unsatisfactory 2.

From the Research

Treatment Overview

The treatment for hypercalcemia typically involves addressing the underlying cause of the condition, as well as managing its symptoms.

• Hydration is often the first step in treatment, with the goal of correcting volume depletion and promoting renal calcium excretion 3, 4, 5, 6, 7.
• Intravenous bisphosphonates, such as zoledronic acid or pamidronate, are commonly used to reduce bone resorption and lower serum calcium levels 3, 4, 5, 6, 7.
• Calcitonin may be used as a temporizing measure to rapidly reduce serum calcium levels, especially in cases of severe symptomatic hypercalcemia 4, 5, 7.
• Glucocorticoids may be effective in treating hypercalcemia associated with certain conditions, such as lymphoma or granulomatous diseases 3, 4, 5.

Specific Treatment Approaches

• For patients with primary hyperparathyroidism, parathyroidectomy may be considered, depending on factors such as age, serum calcium level, and kidney or skeletal involvement 3.
• In patients with kidney failure, denosumab and dialysis may be indicated 3.
• For patients with mild hypercalcemia, observation and monitoring may be appropriate, especially if they are asymptomatic 3.
• In cases of hypercalcemia due to malignancy, treatment of the underlying cancer is essential, and may involve chemotherapy, radiation therapy, or surgery 4, 7.

Additional Considerations

• It is important to identify and treat the underlying cause of hypercalcemia, as this can help to reduce serum calcium levels and improve symptoms 3, 4, 5, 6, 7.
• Patients with severe hypercalcemia may require more aggressive treatment, including hospitalization and close monitoring of their condition 3, 4, 5, 6, 7.
• The prognosis for patients with hypercalcemia varies depending on the underlying cause and the severity of the condition, with asymptomatic primary hyperparathyroidism having a generally excellent prognosis, and hypercalcemia of malignancy being associated with poor survival 3.