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  5. Hypercalcaemia
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Practice points

  • If the patient is asymptomatic with corrected calcium* between 2.62 mmol/l and <2.8 mmol/l, rehydrate with fluids and review as per table in treatment section.
  • Explain signs, symptoms and treatment options to the patient, family and carers.
  • Not all symptoms resolve after treatment. This may be due to other cause(s) or underlying disseminated disease.
  • Bisphosphonates may cause mild flu-like symptoms.
  • Bisphosphonates are implicated risk factors in osteonecrosis of the jaw, osteonecrosis of the auditory canal and atypical fractures. 
  • Where possible, patients should have regular dental checks and avoid invasive dental procedures whilst on treatment.
  • The severity of symptoms is related to the rate of increase; not the level of corrected calcium.
  • The speed of recurrence may signify a poor prognosis.
  • Review current treatments for underlying disease.
  • Untreated severe hypercalcaemia can be fatal.

*Corrected calcium = Measured calcium +0.022 x (40 - serum albumin g/l)

Corrected calcium

Hypercalcaemia flowchart

 

Tables are best viewed in landscape mode on mobile devices

Table 1

Corrected calcium* (mmol/l) Drug and Dose Diluent and maximum infusion rate
  Disodium pamidronate  
2.62 to 3.0 15mg to 30mg 500ml NaCl 0.9% over > 60 minutes
3.0 to 3.5 60mg 500ml NaCl 0.9% over > 60 minutes
3.5 to 4.0 90mg 500ml NaCl 0.9% over > 90 minutes
>4.0 90mg 500ml NaCl 0.9% over > 90 minutes
  Zoledronic acid  
>3.00 4mg 100ml NaCl 0.9% over 15 minutes

If corrected calcium >3.0mmol/l, some units routinely give pamidronate 90mg as a higher dose.

*Corrected calcium = Measured calcium +0.022 x (40 - serum albumin g/l)

 

Reduced doses in renal impairment

  • Disodium pamidronate in renal impairment, seek advice.
  • eGFR >30ml/min: Minimum infusion period 90 minutes, maximum infusion rate 20mg/hour; consider dose reduction.
  • eGFR <30ml/min: avoid except in life threatening hypercalcaemia where specialist advice should be sought to determine if benefit outweighs risk.

 

Zoledronic acid in renal impairment

  • Patients with tumour induced hypercalcaemia  (TIH) and deteriorating renal function should be appropriately assessed to determine if the potential benefit of treatment with zoledronic acid outweighs the possible risk.
  • After 24-48 hours of rehydration, consider a single IV dose of zoledronic acid 4mg in 100ml sodium chloride 0.9% over ≥ 15 minutes. Dose alteration may not be needed in mild to moderate renal impairment in patients with TIH (ie eGFR >30ml/min).
  • Avoid if eGFR <30ml/min, refer to Summary of Product Characteristics (SPCs) (www.medicines.org.uk) for further details.