From the Guidelines
The treatment of hypercalcemia should prioritize hydration and bisphosphonates, with zoledronic acid being the preferred option, as recommended by the most recent guidelines 1.
Initial Management
The initial management of hypercalcemia focuses on hydration using intravenous normal saline to increase calcium excretion.
- Hydration is essential to correct dehydration and enhance renal excretion of calcium.
- Intravenous normal saline is the preferred fluid for hydration.
Bisphosphonates
For moderate to severe hypercalcemia (>12 mg/dL), bisphosphonates are the mainstay of treatment.
- Zoledronic acid (4 mg IV over 15 minutes) or pamidronate (60-90 mg IV over 2-4 hours) are first-line options.
- These medications inhibit osteoclast activity and reduce bone resorption, with effects typically beginning within 2-3 days and lasting several weeks.
- Zoledronic acid is preferred due to its efficacy and safety profile, as stated in the NCCN guidelines 1.
Additional Therapies
Other therapies can be added to manage hypercalcemia, including:
- Calcitonin (4-8 IU/kg SC every 12 hours) for rapid but short-term calcium reduction.
- Denosumab (120 mg SC) as an alternative for patients with renal dysfunction where bisphosphonates are contraindicated.
- Glucocorticoids like prednisone (40-60 mg daily) for hypercalcemia caused by certain conditions like sarcoidosis or vitamin D toxicity.
- Cinacalcet (30-90 mg daily) for hyperparathyroidism-related hypercalcemia.
Monitoring and Long-term Management
Patients should be monitored with regular calcium levels, renal function tests, and electrolyte panels during treatment.
- Addressing the underlying cause of hypercalcemia, whether it's primary hyperparathyroidism, malignancy, or medication effects, is crucial for long-term management.
- Regular follow-up and adjustment of treatment as needed are essential to prevent complications and improve patient outcomes.
From the FDA Drug Label
- 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 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.
Treatment of Hypercalcemia: Calcitonin-salmon injection is indicated for the early treatment of hypercalcemic emergencies. The recommended starting dose is 4 International Units/kg body weight every 12 hours by subcutaneous or intramuscular injection, which can be increased to 8 International Units/kg every 12 hours or every 6 hours if the response is not satisfactory 2.
From the Research
Treatment of Hypercalcaemia
The treatment of hypercalcaemia depends on the severity of the condition and the underlying cause.
- Mild hypercalcaemia usually does not require acute intervention, but in some cases, parathyroidectomy may be considered depending on age, serum calcium level, and kidney or skeletal involvement 3.
- Initial therapy for symptomatic or severe hypercalcaemia consists of hydration and intravenous bisphosphonates, such as zoledronic acid or pamidronate 3, 4, 5, 6, 7.
- In patients with kidney failure, denosumab and dialysis may be indicated 3, 6.
- Glucocorticoids may be used as primary treatment when hypercalcaemia is due to excessive intestinal calcium absorption (vitamin D intoxication, granulomatous disorders, some lymphomas) 3, 4, 7.
Management of Acute Hypercalcaemia
Acute hypercalcaemia is a life-threatening condition that requires immediate attention.
- The first step in management is to restore normovolemia to prevent renal impairment, followed by restoration of renal function and enhancement of renal excretion of calcium 5.
- Five keystones in the treatment of hypercalcaemic crisis should be considered:
- Restore normovolemia to prevent renal impairment
- Restore renal function and enhance renal excretion of calcium
- Dialysis
- Inhibit osteoclastic bone resorption
- Reduce intestinal calcium absorption 5.
- Bisphosphonates are the drugs of choice in most patients after adequate hydration, while non-bisphosphonate drugs, such as calcitonin, gallium nitrate, and mithramycin, are now rarely used 5, 7.
Emergency Management
Emergency management of hypercalcaemia is based on intravenous rehydration with normal saline, but when this is inadequate, bisphosphonate therapy is used 6.