Treatment of Hypercalcaemia

• Optimal treatment varies according to cause and severity of hypercalcaemia.
• The degree of hypercalcemia, along with the rate of rise of serum calcium concentration, often determines symptoms and the urgency of therapy.
• If possible, treat underlying cause of hypercalcaemia

Hypercalcaemia status	Treatment
Mild (<3mmol/L serum Ca)	No immediate treatment needed
Moderate (3-3.4mmol/L)	No immediate treatment needed, unless rapid rise in serum Ca
Severe (>3.5mmol/L)	Immediate treatment needed

Treatment options

1. Rehydration and saline diuresis
2. Steroids-effective in myeloma, other haematological malignancies, sarcoi dosis, vit D excess
3. Calcitonin- rapid control of severe hypercalcaemia
4. Bisphosphonate-treatment of choice in hypercalcaemia of malignancy and primary hyperparathyroidism.
5. Mithramycin (Plicamycin)-used if bisphosphonate is not effective in hypercalcaemia of malignancy
6. Dialysis - indicated for severe cases (serum Ca>4.5mmol/L and neurologic symptom) or with renal failure.

Comments (Sarawak handbook recommendations)
Normal saline: Initially, 0.45-0.9% NS infused at 300-500ml/hr and reduced when ECF volume deficit is partially corrected, 3-4L/day. IV frusemide 20-40mg tds-qid
Calcitonin 4-8IU/kg IM or SC q6-12h up to 3 days
Hydrocortisone IV 200mg q6-8h or prednisolone 30-60-mg daily
Pamidronate single dose of 30mg (3mmol/L serum Ca), 60mg (3-3.4mmol/L), 90mg (>3.5mmol/L). Dose may be repeated at least 7 days after the first dose. Zoledronate preferred over pamidronate for hypercalcaemia of malignancy

Availability
0.45-0.9% NS
IV Frusemide 10mg/ml(B)
IV Pamidronate 30mg (A*)
IV Hydrocortisone 100mg (C)
T. Prednisolone 5mg (B)

References

1. Sarawak Handbook of Medical Emergencoes 3 ed.
2. Up-To-Date
3. A practical approach to hypercalcaemia. Am Fam Physician. 2003 May 1;67(9):1959-1966