What is the management for a 75-year-old patient with hypercalcemia?

Management of Hypercalcemia in a 75-Year-Old Patient

Aggressive intravenous hydration with normal saline followed by intravenous bisphosphonate therapy (preferably zoledronic acid 4 mg) is the recommended first-line treatment for a 75-year-old patient with significant hypercalcemia of 11.6 mg/dL. 1

Initial Assessment and Workup

• Evaluate for symptoms: confusion, lethargy, nausea, vomiting, constipation, polyuria, dehydration
• Obtain immediate labs:
  • Intact parathyroid hormone (PTH) level to differentiate PTH-dependent from PTH-independent causes 2
  • Renal function (creatinine, BUN)
  • Electrolytes (particularly magnesium, phosphate, potassium)
  • 25-OH Vitamin D level 3

Immediate Management

1. Hydration:

   • Begin aggressive IV hydration with normal saline (0.9% NaCl) 1
   • Target urine output of 100-150 mL/hour 1
   • Avoid volume overload, especially in patients with cardiac or renal disease

2. Bisphosphonate Therapy:

   • Administer zoledronic acid 4 mg IV over at least 15 minutes after adequate hydration 4
   • Alternative: pamidronate 60-90 mg IV if zoledronic acid unavailable 3
   • Adjust dose for renal impairment according to creatinine clearance 4

3. Loop Diuretics:

   • Only after adequate hydration is achieved 1
   • Furosemide can enhance calcium excretion
   • Avoid thiazide diuretics as they decrease renal calcium excretion 1

Monitoring

• Daily calcium, renal function, and electrolytes until stable 1
• Monitor for hypocalcemia, hypophosphatemia, and hypomagnesemia 4
• Assess volume status with daily weights and intake/output monitoring 1

Cause-Specific Management

If Primary Hyperparathyroidism (elevated or inappropriately normal PTH):

• Surgical consultation for parathyroidectomy if meeting criteria for surgery 3
• Consider calcimimetics (cinacalcet) for patients who are not surgical candidates 3
• Caution with cinacalcet due to potential for hypocalcemia and QT interval prolongation 3

If Malignancy-Associated Hypercalcemia (suppressed PTH):

• Bisphosphonates are the mainstay of treatment 3
• Consider denosumab 120 mg SC if hypercalcemia is refractory to bisphosphonates 1
• Calcitonin may be used for rapid but short-term calcium reduction 3

If Vitamin D-Related Hypercalcemia:

• Consider glucocorticoids 3
• Discontinue vitamin D supplements 1

Common Pitfalls to Avoid

1. Inadequate hydration: Dehydration worsens hypercalcemia and renal function 1
2. Premature use of loop diuretics: Can worsen volume depletion if given before adequate hydration 1
3. Neglecting electrolyte monitoring: Hypokalemia and hypomagnesemia can complicate treatment 1
4. Delayed treatment: Can lead to rapid deterioration of renal function 1
5. Administering bisphosphonates too quickly: Infusion should be over at least 15 minutes to prevent renal damage 4

Long-Term Management

• Identify and treat the underlying cause
• For primary hyperparathyroidism:
  • Parathyroidectomy for patients meeting surgical criteria 3
  • Regular monitoring of calcium, PTH, and renal function for non-surgical patients
• For malignancy-associated hypercalcemia:
  • Treat the underlying malignancy
  • Consider maintenance bisphosphonate therapy 3

The prognosis depends on the underlying cause, with primary hyperparathyroidism having an excellent prognosis with appropriate management, while malignancy-associated hypercalcemia generally indicates poor survival 2.