Patients with cancer frequently have low albumin, which must be taken into account prior to treatment determination. After a thorough history and physical exam, contributing factors such as medications or excessive calcium dietary intake (including TPN solutions) should be weaned as tolerated.
Although there are no formal treatment guidelines, most patients with hypercalcemia are not treated until serum calcium is greater than 12 mg/dL, the patient is experiencing worsening symptoms, or when there is an acute rise in calcium that is precipitating symptoms.1
Initial treatment of hypercalcemia includes aggressive intravenous hydration with normal saline solution with close monitoring of the patient’s volume status.
Once a patient is adequately rehydrated, initiation of intravenous furosemide (a loop diuretic) is sometimes utilized to help promote additional calcium excretion. Additional agents that are commonly used to treat hypercalcemia in oncology patients include calcitonin and the intravenous bisphosphonates pamidronate and zoledronic acid.
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When comparing the two primary bisphosphonates, zoledronic acid has superior efficacy in hypercalcemia secondary to malignancy and is the drug of choice.1,4
A patient’s malignancy can frequently contribute to hypercalcemia, however it is extremely important to rule out other potential causes that may be on the differential diagnosis.
In addition to closely monitoring the patient’s clinical and serum calcium levels during treatment, it is also important to monitor all additional electrolytes including phosphate, potassium, and magnesium as well as their kidney function.
- Stewart AF. Clinical practice. Hypercalcemia associated with cancer. N Engl J Med. 2005;352(4):373-379.
- Inzucchi SE. Understanding hypercalcemia. Its metabolic basis, signs, and symptoms. Postgrad Med. 2004;115(4):69-70, 73-76.
- Carroll MF, Schade DS. A practical approach to hypercalcemia. Am Fam Physician. 2003;67(9):1959-1966.
- Major P, Lortholary A, Hon J, et al. Zoledronic acid is superior to pamidronate in the treatment of hypercalcemia of malignancy: a pooled analysis of two randomized, controlled clinical trials. J Clin Oncol. 2001;19(2):558-567.