What is the treatment approach in all patients?
Ensure adequate supportive care.
Identify and treat the underlying cause (see “Etiology of hypercalcemia”).
Consider consulting endocrinology, nephrology, oncology, and/or surgery services as needed.
What is the approach for patients with Severe hypercalcemia and symptomatic moderate hypercalcemia?
Rapidly lower calcium levels.
Start IV fluid therapy with 0.9% NaCl.
Consider adding diuretics if there is volume overload.
Initiate pharmacotherapy: e.g., calcitonin, bisphosphonates, denosumab.
Consider targeted therapy based on suspected etiology: e.g., surgery, calcimimetics, corticosteroids.
Treat any complications: e.g., arrhythmias, nephrolithiasis.
Consider hemodialysis for refractory life-threatening hypercalcemia or if other therapies are contraindicated (e.g., bisphosphonates in severe renal failure).
What is the approach for patients with Mild hypercalcemia or asymptomatic moderate hypercalcemia
Acute treatment other than supportive care and treatment of the underlying cause is usually not necessary.
Follow calcium levels and monitor for the development of symptoms. [2]
Describe the supportive care.
Ensure adequate hydration.
Reduce dietary intake of calcium.
Avoid potentially aggravating medications (e.g., thiazides, lithium, vitamin D, calcidiol, calcitriol).
Encourage mobility and avoid prolonged bed rest/inactivity.
Describe the fluid therapy and volume status management.
IV fluid repletion with 0.9% NaCl : typically 4–6 L in 24 hours
Obtain serial calcium checks and monitor urine output and volume status.
Consider IV loop diuretic (e.g. IV furosemide) ONLY if there are signs of volume overload (e.g., pulmonary congestion, significant peripheral edema).
Thiazide diuretics enhance Tubular calcium upTake: Discontinue them in hypercalcemia. Loop diuretics Lose calcium: They may be used to treat fluid overload in patients with hypercalcemia.
Describe the standard pharmacotherapy.
Pharmacotherapy is aimed at inhibiting bone resorption.
Consider calcitonin for rapid-onset, short-term control of hypercalcemia.
Bisphosphonates for slow-onset, long-term control of hypercalcemia
Options
Zoledronic acid
Pamidronate
Contraindicated in severe CKD (CrCl < 30 mL/min)
Describe targeted therapies.
Hypercalcemia due to primary or tertiary hyperparathyroidism [4][14]
Surgical management preferred: partial or total parathyroidectomy
Calcimimetics (e.g., cinacalcet) for patients unable to undergo surgery
See “Treatment” in “Hyperparathyroidism.”
Hypercalcemia due to lymphoma, granulomatous diseases, or vitamin D intoxication: systemic glucocorticoids (e.g., prednisone) [3]
List alternative therapeutic options.
These treatment options may be considered if hypercalcemia is resistant to other measures or the use of bisphosphonates is contraindicated due to severe renal failure.
Denosumab
Hemodialysis may additionally be considered in the following circumstances:
Aggressive fluid repletion is contraindicated (e.g., patients with fluid overload due to severe heart failure or oliguric AKI).
Immediate reduction of calcium levels is necessary due to life-threatening symptomatic hypercalcemia.
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