Therapies for Severe Hypercalcemia | ||||
| TREATMENT | ONSET OF ACTION | DURATION OF ACTION | ADVANTAGES | DISADVANTAGES |
|---|---|---|---|---|
| Most useful therapies | ||||
| Hydration with normal saline | Hours | During infusion | Rehydration invariably needed | Volume overload |
| Forced diuresis; normal saline plus loop diuretic | Hours | During treatment | Rapid action | Volume overload, cardiac decompensation, intensive monitoring, electrolyte disturbance, inconvenience |
| Pamidronate | 1-2 days | 10-14 days to weeks | High potency; intermediate onset of action | Fever in 20%, hypophosphatemia, hypocalcemia, hypomagnesemia, rarely jaw necrosis, atypical femoral fracture |
| Zolendronate | 1-2 days | >3 weeks | Same as for pamidronate (lasts longer) | Same as pamidronate above |
| Denosumab | 1-2 days | >3 weeks | Strongest antiresorptive | Occasional severe hypocalcemia, rarely jaw necrosis, skin infections, atypical femoral fracture |
| Special-use therapies | ||||
| Calcitonin | Hours | 1-2 days | Rapid onset of action; useful as adjunct in severe hypercalcemia | Rapid tachyphylaxis |
| Phosphate oral | 24 h | During use | Chronic management (with hypophosphatemia); low toxicity if P < 4 mg/dL | Limited use except as adjuvant or chronic therapy |
| Glucocorticoids | Days | Days, weeks | Oral therapy, antitumor agent | Active only in certain malignancies, vitamin D excess and sarcoidosis; glucocorticoid side effects |
| Dialysis | Hours | During use and 24-48 h afterward | Useful in renal failure; onset of effect in hours; can immediately reverse life-threatening hypercalcemia | Complex procedure, reserved for extreme or special circumstances |