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Hypercalcaemia is the commonest life-threatening metabolic disorder associated with advanced cancer. It occurs in approximately 10% of patients with cancer.
Hypercalcaemia can occur in any malignancy but is most common in cancers of the breast, squamous cell carcinomas (e.g. bronchus, upper oesophagus), lymphoma, myeloma, kidney and bladder.
Patients may be asymptomatic, and symptoms are often more related to the rate of rise rather than to the absolute level of the calcium. Serious or distressing symptoms may present with a relatively small elevation of the serum calcium or very high calcium may produce few symptoms.
Normal range: normal serum corrected calcium is 2.2-2.6mmol/LA decision to treat should be based upon:
Oral fluids
Intravenous fluids
See section 6.6.2 Bisphosphonates and other drugs affecting bone metabolism
The Summary of Product Characteristics (SPC) recommends a dose dependent on the initial albumin-corrected plasma concentration:
(manufacturer's recommendations)
Corrected plasma calcium concentration | Dose |
less than 3 mmol/L | 15 or 30mg |
3 – 3.5 mmol/L | 30 or 60mg |
3.5 – 4 mmol/L | 60 or 90mg |
greater than 4 mmol/L | 90mg |
However, it has been suggested the higher dose should be given irrespective of the initial calcium level to increase the probability of a response and prolong its duration.
See section 6.6.2 Bisphosphonates and other drugs affecting bone metabolism
Patients should be well hydrated
Give 4mg IV in 100ml 0.9% saline or 5% glucose over 15 minutes
Measure plasma creatinine before each dose, no adjustment is required in mild-moderate renal impairment.
It takes 2-7 days to achieve maximum effect, and corrected calcium levels should be checked after approximately 5 days. The average duration of effect is 20-30 days.
If calcium does not return to within normal range and patient remains symptomatic, options include repeating bisphosphonate infusion after 1 week or changing to alternative bisphosphonate.
Monitor corrected calcium levels every 3-4 weeks or when symptoms occur.
If needing to retreat within 3 weeks, or for patients with resistant hypercalcaemia, please seek specialist advice
Some patients may be receiving denosumab (Xgeva), a monoclonal antibody treatment for bone metastases secondary to solid tumours, as part of their oncology treatment regime. It is also an option for treating refractory hypercalcaemia of malignancy (unauthorised indication).