Therapeutic Handbook - GGC Prescribing

Management of HypercalcaemiaThis guideline is under review. Please see the online version of the handbook for the most up to dateguidance. In addition, for guidance on bisphosphonate use in cancer patients see www.intranet.woscan.scot.nhs.uk / Systemic anti-cancer therapy protocols / Supportive careIntroductionThe reference range for adjusted serum calcium is 2.1 - 2.6 mmol/L.N.B. In patients presenting with hypercalcaemia in an emergency setting always consider occultmalignancy. Low serum albumin is another pointer to this being the cause.Assessment / monitoring• Serum calcium should be monitored daily.• U&Es to assess hydration status.Electrolyte DisturbancesDrug therapy / treatment optionsIf hypercalcaemia is life-threatening (adjusted calcium > 4 mmol/L), start:Sodium chloride 0.9% IV 1 litre over 4 hours and contact senior medical staff for adviceimmediately. Dialysis may be needed.Otherwise carefully rehydrate with:Sodium chloride 0.9% IV infusion 2 - 3 L over 24 hours to maintain urine output andpromote calcium excretion.• More cautious rehydration will be necessary if the patient has a history of heart failure, renalfailure or is elderly.• Ensure thiazide diuretics are discontinued.• After 24 - 48 hours of rehydration, consider intravenous pamidronate if the condition remainsunresolved (see Table 1).Table 1 – IV Pamidronate dosingInitial serum calcium (adjusted)mmol/LRecommended total dose (mg) for tumour-inducedhypercalcaemiaUp to 3 mmol/L 15 - 303 - 3.5 mmol/L 30 - 603.5 - 4 mmol/L 60 - 90> 4 mmol/L 90Continues on next pagePage 304