What is the treatment for Hypercalcemia?

From the Guidelines

Hypercalcemia should be treated with hydration, bisphosphonates, denosumab, steroids, and/or calcitonin, with zoledronic acid being the preferred bisphosphonate. The treatment approach depends on the severity and underlying cause of hypercalcemia. For mild cases, adequate hydration and addressing the underlying cause may be sufficient. However, for moderate to severe hypercalcemia, initial management includes aggressive IV fluid rehydration with normal saline, followed by loop diuretics like furosemide to enhance calcium excretion 1.

Key Treatment Components

• Bisphosphonates, specifically zoledronic acid, are first-line medications for hypercalcemia of malignancy, as they have been shown to be effective in reducing calcium levels 1.
• Calcitonin can provide rapid but short-term relief, and denosumab may be used for refractory cases.
• Dialysis should be considered in severe cases with renal failure.
• Treating the underlying cause, whether primary hyperparathyroidism, malignancy, or medication effects, is crucial for long-term management.

Monitoring and Follow-Up

Patients should be monitored with regular calcium levels, renal function tests, and electrolyte measurements during treatment. This approach is supported by the most recent guidelines, which emphasize the importance of timely and effective treatment to prevent complications and improve patient outcomes 1.

From the FDA Drug Label

Zoledronic acid injection is indicated for the treatment of hypercalcemia of malignancy defined as an albumin-corrected calcium (cCa) of greater than or equal to 12 mg/dL [3.0 mmol/L] The maximum recommended dose of zoledronic acid injection in hypercalcemia of malignancy (albumin-corrected serum calcium greater than or equal to 12 mg/dL [3. 0 mmol/L]) is 4 mg. Patients who receive zoledronic acid injection should have serum creatinine assessed prior to each treatment Consideration should be given to the severity of, as well as the symptoms of, tumor-induced hypercalcemia when considering use of zoledronic acid injection. Vigorous saline hydration, an integral part of hypercalcemia therapy, should be initiated promptly and an attempt should be made to restore the urine output to about 2 L/day throughout treatment.

Hypercalcemia Treatment with Zoledronic Acid:

• The recommended dose is 4 mg infused over no less than 15 minutes.
• Patients should be adequately rehydrated prior to administration.
• Retreatment may be considered if serum calcium does not return to normal or remain normal after initial treatment, with a minimum of 7 days elapsing before retreatment.
• Renal function must be carefully monitored in all patients receiving zoledronic acid injection 2.

From the Research

Hypercalcemia Treatment Overview

• Hypercalcemia is a condition that affects approximately 1% of the worldwide population, with primary hyperparathyroidism (PHPT) and malignancy being the most common causes 3.
• Treatment of hypercalcemia depends on the underlying cause, with mild cases often not requiring acute intervention, while severe cases require immediate attention 3, 4.

Treatment Options

• Hydration is the first line of treatment for hypercalcemia, with intravenous bisphosphonates such as zoledronic acid or pamidronate being used for severe cases 3, 4, 5.
• Glucocorticoids may be used as primary treatment for hypercalcemia due to excessive intestinal calcium absorption, such as vitamin D intoxication or granulomatous disorders 3, 4, 6.
• Denosumab and dialysis may be indicated in patients with kidney failure 3, 7.
• Calcitonin may be used for immediate short-term management of severe symptomatic hypercalcemia 4, 6.

Management of Severe Hypercalcemia

• Severe hypercalcemia is a life-threatening condition that requires urgent management, with saline hydration, furosemide, and zoledronic acid being commonly used treatments 5.
• Zoledronic acid has been shown to be more potent than furosemide in reducing serum calcium levels in patients with severe hypercalcemia secondary to PHPT 5.
• Parathyroidectomy may be considered in patients with PHPT, depending on age, serum calcium level, and kidney or skeletal involvement 3, 7.

Prognosis and Outcome

• The prognosis for asymptomatic PHPT is excellent with either medical or surgical management, while hypercalcemia of malignancy is associated with poor survival 3.
• Treatment of hypercalcemia can reduce serum calcium and improve symptoms, at least transiently, with the underlying cause of hypercalcemia being identified and treated 3, 4.