Template:Hypercalcemia treatment: Difference between revisions
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===Symptomatic or Severe hypercalcemia (Ca >14 mg/dL)=== | ===Symptomatic or Severe hypercalcemia (Ca >14 mg/dL)=== | ||
*Patients are likely dehydrated and require saline hydration as initial therapy | *Patients are likely dehydrated and require [[normal saline|saline]] hydration as initial therapy | ||
====Hydration==== | ====Hydration==== | ||
*Isotonic saline at 200-300 mL/hour; adjust to maintain urine output at 100-150 mL/hour | *Isotonic [[normal saline|saline]] at 200-300 mL/hour; adjust to maintain urine output at 100-150 mL/hour | ||
====[[Calcitonin]]==== | ====[[Calcitonin]]==== | ||
| Line 17: | Line 17: | ||
====Bisphosphonates==== | ====Bisphosphonates==== | ||
Give for severe hypercalcemia due to excessive bone resorption (lowers Ca within 12-48hr) | Give for severe hypercalcemia due to excessive bone resorption (lowers Ca within 12-48hr)[≥12 mg/dL][≥3 mmol/L]<ref>Shane et al. Uptodate: Treatment of Hypercalcemia. https://www.uptodate.com/contents/treatment-of-hypercalcemia#disclaimerContent</ref> | ||
*Pamidronate 90mg IV over 24 hours OR | *Pamidronate 90mg IV over 24 hours OR | ||
*[[Zoledronate]] 4mg IV over 15 minutes | *[[Zoledronate]] 4mg IV over 15 minutes | ||
*Caution in renal failure, though bisphosphonates have been safely used in pts with pre-existing renal failure<ref>LeGrand SB et al. Narrative Review: Furosemide for Hypercalcemia: An Unproven yet Common Practice. Ann Intern Med. 2008;149:259-263.</ref> | *Caution in renal failure, though bisphosphonates have been safely used in pts with pre-existing renal failure<ref>LeGrand SB et al. Narrative Review: Furosemide for Hypercalcemia: An Unproven yet Common Practice. Ann Intern Med. 2008;149:259-263.</ref> | ||
====Electrolyte Repletion==== | ====[[electrolyte repletion|Electrolyte Repletion]]==== | ||
*Correct [[hypokalemia]] | *Correct [[hypokalemia]] | ||
*Correct [[hypomagnesemia]] | *Correct [[hypomagnesemia]] | ||
====Diuresis==== | ====[[diuretics|Diuresis]]==== | ||
*[[Furosemide]] is NOT routinely recommended | *[[Furosemide]] is NOT routinely recommended | ||
*Only consider in patients with renal insufficiency or heart failure and volume overload | *Only consider in patients with renal insufficiency or heart failure and volume overload | ||
====Dialysis==== | ====[[Dialysis]]==== | ||
Consider if patient: | Consider if patient: | ||
*Anuric with | *Anuric with [[renal failure]] | ||
*Failing all other therapy | *Failing all other therapy | ||
*Severe hypervolemia not amenable to diuresis | *Severe [[fluid overload|hypervolemia]] not amenable to diuresis | ||
*Serum Calcium level >18mg/dL | *Serum Calcium level >18mg/dL | ||
*Neurologic symptoms | |||
*Heart failure with reduced ejection fraction (unable to provide fluids) | |||
====[[Corticosteroids]]==== | ====[[Corticosteroids]]==== | ||
''Decrease Ca mobilization from bone and are helpful with steroid-sensitive tumors (e.g. lymphoma, MM)'' | ''Decrease Ca mobilization from bone and are helpful with steroid-sensitive tumors (e.g. lymphoma, MM)'' | ||
*[[Prednisone]] 60mg PO daily | *[[Prednisone]] 60mg PO daily | ||
Latest revision as of 14:14, 25 August 2022
Asymptomatic or Ca <12 mg/dL
- Does not require immediate treatment
- Advise to avoid factors that can aggravate hypercalcemia (thiazide diuretics, Li, volume depletion, prolonged inactivity, high Ca diet)
Mildly symptomatic Ca 12-14 mg/dL
- May not require immediate therapy; however, an acute rise may cause symptoms necessitating treatment as described for severe hypercalcemia (see below)
Symptomatic or Severe hypercalcemia (Ca >14 mg/dL)
- Patients are likely dehydrated and require saline hydration as initial therapy
Hydration
- Isotonic saline at 200-300 mL/hour; adjust to maintain urine output at 100-150 mL/hour
Calcitonin
- Consider adding calcitonin 4 units/kg SC or IV q12hr in patients w/ Ca >14 mg/dL (3.5 mmol/L) who are also symptomatic (lowers Ca w/in 2-4hr)
- Tachyphylaxis limits use long term, but is a great choice for emergent cases
Bisphosphonates
Give for severe hypercalcemia due to excessive bone resorption (lowers Ca within 12-48hr)[≥12 mg/dL][≥3 mmol/L][1]
- Pamidronate 90mg IV over 24 hours OR
- Zoledronate 4mg IV over 15 minutes
- Caution in renal failure, though bisphosphonates have been safely used in pts with pre-existing renal failure[2]
Electrolyte Repletion
- Correct hypokalemia
- Correct hypomagnesemia
Diuresis
- Furosemide is NOT routinely recommended
- Only consider in patients with renal insufficiency or heart failure and volume overload
Dialysis
Consider if patient:
- Anuric with renal failure
- Failing all other therapy
- Severe hypervolemia not amenable to diuresis
- Serum Calcium level >18mg/dL
- Neurologic symptoms
- Heart failure with reduced ejection fraction (unable to provide fluids)
Corticosteroids
Decrease Ca mobilization from bone and are helpful with steroid-sensitive tumors (e.g. lymphoma, MM)
- Prednisone 60mg PO daily
- ↑ Shane et al. Uptodate: Treatment of Hypercalcemia. https://www.uptodate.com/contents/treatment-of-hypercalcemia#disclaimerContent
- ↑ LeGrand SB et al. Narrative Review: Furosemide for Hypercalcemia: An Unproven yet Common Practice. Ann Intern Med. 2008;149:259-263.