What is the immediate management for a patient with hypercalcemia?

Immediate Management of Hypercalcemia

Begin immediate intravenous normal saline hydration to correct hypovolemia and promote calciuresis, followed by intravenous bisphosphonate therapy (zoledronic acid or pamidronate) for moderate to severe hypercalcemia. 1, 2, 3

Initial Stabilization

Aggressive Hydration (First-Line)

• Administer IV normal saline immediately to restore extracellular volume and enhance urinary calcium excretion 1, 3
• Target urine output of at least 100 mL/hour (or 3 mL/kg/hour in children <10 kg) 1
• Adequate hydration is an integral part of hypercalcemia therapy and should be initiated promptly 2
• Avoid overhydration in patients with cardiac failure or renal insufficiency 2

Loop Diuretics (Selective Use)

• Do not administer diuretics prior to correction of hypovolemia 2
• Loop diuretics (furosemide) may be necessary only in patients with renal or cardiac insufficiency to prevent fluid overload 1
• Evidence shows furosemide provides no significant additional benefit beyond saline hydration alone in severe hypercalcemia from primary hyperparathyroidism 4

Definitive Pharmacologic Treatment

Bisphosphonates (First-Line for Moderate-Severe Hypercalcemia)

• Zoledronic acid is the preferred bisphosphonate for hypercalcemia treatment, typically dosed at 4 mg IV 1, 2
• Pamidronate is an alternative bisphosphonate option for moderate or severe hypercalcemia associated with malignancy 2
• Bisphosphonates reduce serum calcium to near normal in most patients within 3 to 6 days 5
• Do not delay bisphosphonate therapy in moderate to severe hypercalcemia, as they should be administered early despite delayed onset of action 6, 5
• Monitor serum ionized calcium concentration to prevent hypercalcemia when using calcium infusions for other indications 7

Calcitonin (Rapid-Acting Adjunct)

• Calcitonin-salmon 100 IU subcutaneously or intramuscularly provides rapid but modest calcium reduction 6
• Use calcitonin as a bridge until bisphosphonates take effect, or in patients who cannot tolerate other treatments 6
• Combining calcitonin with bisphosphonates enhances the rate of serum calcium decline 5

Glucocorticoids (Cause-Specific)

• Glucocorticoids are effective as primary treatment for vitamin D-mediated hypercalcemia, including sarcoidosis, lymphomas, and vitamin D intoxication 6, 3
• Do not use glucocorticoids as first-line therapy for hypercalcemia of malignancy or primary hyperparathyroidism 8

Severity-Based Approach

Mild Hypercalcemia (Total Ca <12 mg/dL or ionized Ca 5.6-8.0 mg/dL)

• Conservative management with saline hydration is often sufficient 2, 3
• Observation may be appropriate in patients >50 years with calcium <1 mg above upper normal limit and no skeletal or kidney disease 3

Severe Hypercalcemia (Total Ca ≥14 mg/dL or ionized Ca ≥10 mg/dL)

• Requires urgent treatment with aggressive IV hydration plus bisphosphonates 3
• Consider dialysis in patients with severe hypercalcemia complicated by renal insufficiency 1, 8
• Hemodialysis effectively removes calcium through diffusive therapy 1

Special Considerations

Renal Failure

• Denosumab and dialysis may be indicated when bisphosphonates are contraindicated 3
• Avoid NSAIDs and intravenous contrast media in patients with renal impairment 6

Malignancy-Associated Hypercalcemia

• Treatment of the underlying cancer is essential for long-term control 6
• Plasmapheresis may be used as adjunctive therapy for symptomatic hyperviscosity in multiple myeloma 1

Monitoring

• Monitor serum calcium, renal function, and electrolytes regularly to assess treatment effectiveness 1, 6
• Correct potassium and magnesium deficiencies as part of comprehensive management 5

Critical Pitfalls to Avoid

• Never administer loop diuretics before correcting hypovolemia, as this worsens calcium excretion 2
• Do not restrict calcium intake without medical supervision in normocalcemic patients 6
• Avoid vitamin D supplements in all patients with hypercalcemia 1, 6
• Do not delay bisphosphonate administration while waiting for diagnostic workup in symptomatic patients 6