Patients with mild hypercalcemia (<12 mg / dL)
have no indications for immediate treatment. It may be advisable to increase
fluid intake to reduce the risk of nephrolithiasis.
Intermediate hypercalcemia
(12-14 mg / dL) may not require immediate treatment. An acute rise in serum
calcium can cause significant impairment in mental status and requires urgent
treatment.
Severe hypercalcemia (>
14 mg / dL) should be treated;
The isotonic saline should
be given at a rate of 200-300 mL / h and a rate of 100-150 mL / h urine output.
If there is no heart / kidney failure, it is not necessary to give loop
diuretics.
Calcitonin (4 IU / kg)
should be given and serum calcium measured after hours. If hypocalcemic
response is observed, this can be repeated every 6 to 12 hours (4-8 IU / kg).
Zolendronic acid (4 mg
i.v., over a 15 minute period) should be started concurrently with treatment.
The other alternative is pamidronate.
Administration of saline
with calcitonin will cause a reduction in calcium in 12 to 48 hours. The
bisphosphonate reduces serum calcium within 2 to 4 days.
Donesumab is an
alternative drug in a patient with malignant, Zolendronic acid-resistant,
severe hypercalcemia.
Hemodialysis.
The most common cause of
hypercalcemia in non-hospitalized patients is HYPERPARATHYROIDISM.
Hydration with isotonic NaCl
Hypovolemia causes
hypercalcemia by impairing renal clearance of calcium.
With saline treatment,
hypercalcemia on a moderate level often does not become normal. Simultaneous
bisphosphonates should also be initiated. If necessary calcitonin can be
started.
Calcitonin
At pharmacological doses,
calcitonin acts by increasing renal calcium excretion and, more importantly, by
impairing osteoclast function and reducing bone resorption. Nasal form is not
successful in hypercalcemia treatment.
Calcitonin is safe and
does not have major toxicities. The effect is fast despite the weakness. It
starts in six hours and reduces calcium up to 1-2 mg / dL maximum. Probably due
to receptor down-regulation, tachyphylaxis develops within 48 hours.
Bisphosphonates
Bisphosphonates are nonhidrolizable
analogs of inorganic phosphate adsorbing to the surface of bone hydroxyapatite.
It disrupts osteoclast-mediated bone resorption and impairs calcium release.
Although zoledronic acid
has the potential to cause osteonecrosis of the jaw, it is a side effect that
is more commonly seen in chronic use.
The efficacy of
zolendronic acid 4 mg and 8 mg doses were similar. 8 mg was associated with
more renal toxicity.
Pamidronate is more effective than etidronate or
clodronate.
Ibandronate 2mg / 4mg /
6mg is also effective in hypercalcemia. The efficacy is greater at 4 mg and 6
mg, but duration of action is dose independent.
Ibandronate appears to be
as effective as pamidronate.
Clodronate and etidronate
are relatively low-impact first-generation bisphosphonates. If the other
bisphosphonates are not aviable, these two agents can be used.
Glucocorticoids
Where absorption of
vitamin D-related dietary calcium is increased, glucocorticoids reduce the
production of calcitriol within 2-5 days.
Denosumab
DenoSumab has a 60 mg
injector and is used weekly.
It can also be used in
chronic kidney failure. Optimal dosing is not clear in renal failure. The risk
of hypocalcemia seems to be more in chronic kidney disease.
If the first dose is as
low as 0.3 mg / kg, and if the target is not reached within 1 week, the second
injection may be recommended as a prudent approach, considering the risk of
hypocalcemia.
Measuring vitamin D levels
prior to denosumab may also be warranted, because those with vitamin D
deficiency are more susceptible to hypocalcemia. Even if the measurement of
vitamin D levels is delayed, give vitamin D 50000 IU 1-2 days before donesumab;
If the result is Vitamin D deficiency you will continue treatment; If there are
no deficiencies, you will end up giving vitamin D. Some authors advocate this
view.
Calcimimetics
Sinekalset
Dialysis
It is the approach to be
considered in the last stage.
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