Hypercalcemia of Malignancy

• Hypercalcemia of Malignancy (HCM) is an oncologic emergency typically seen in patients with advanced stage

cancers

• HCM is more common in patients with tumors that are associated with bone metastases (breast, lung, multiple

myeloma, renal cell carcinoma and colorectal cancer)

• Hypercalcemia is defined as a corrected calcium level > 10.5 mg/dL
• Symptoms occur slowly (or may be absent) and can include nephrolithiasis, polyuria, polydipsia, gout, ventricular

tachyarrhythmias, fatigue, anorexia, cognitive dysfunction, etc.

• Management of hypercalcemia is traditionally with aggressive IV fluids, calcitonin, and bisphosphonates. Loop

diuretics and steroids have a limited role in treatment for most patients.

Calcitonin

Bisphosphonates

Role in

Therapy

Used to provide a transient

decrease in serum calcium levels

Used with aggressive fluid

hydration and IV bisphosphonates

Should be administered ASAP after diagnosis

Mechanism

Inhibits osteoclastic bone

resorption and promotes renal

excretion of calcium

Deposits into bone and lowers calcium levels

by inhibiting osteoclastic bone resorption

Dose

4 IU/kg IM/SQ Q12 hours x48 hours

Zoledronic Acid (Zometa)

4mg IV over 15-30 minutes (NO dose

adjustments needed for HCM indication)

SCr must be < 4.5 mg/dL

Pamidronate

90 mg IV over 4 hours

May use if SCr > 4.5 mg/dL

PK/PD

Onset of action: 4-6 hours

Efficacy limited to 48 hours due to

tachyphylaxis

Onset of action: 48 hours (maximal effect: 2-4

days)

Evidence details are preserved from the source document in the clinical sections and references.

• Reported in 20 – 30% of cancer patients and is a poor prognostic indicator
• Primarily associated with lung and breast cancer, as well as myeloma and lymphoma
• Presentation can range from asymptomatic to progressive mental impairment, arrhythmias,

and renal failure

• Cornerstones of therapy include aggressive hydration, calcitonin, and IV bisphosphonates

[email protected];

Micromedex [Electronic version].Greenwood Village, CO: Truven Health Analytics. Retrieved October 6, 2020, from

http://www.micromedexsolutions.com/

Goldner, W. Cancer-Related Hypercalcemia. Journal of Oncology Practice. 2016; 12:5, 426-432.

Stewart AF. Hypercalcemia of Malignancy. N Engl J Med 2005; 352:373-9.

Feldenzer, K, Sarno J. Hypercalcemia of Malignancy. J Adv Pract Oncol. 2018; 9(5):496-504.

Major P, et al. J Clin Oncol. 2001;19(2):558-567.

Hu MI, et al. J Clin Endocrinol Metab. 2014 Sep; 99(9): 3144-3152.

Kammerman S, et al. J Clin Endocrinol Metab. 1970 Jul;31(1):70-5.

Thiébaud D, et al P. Arch Intern Med. 1990 Oct;150(10):2125-8.

Sabry NA, et al. Med Oncol. 2011 Jun;28(2):584-90.

• Sleeboom HP, et al. Lancet. 1983 Jul 30;2(8344):239-43.
• Hosking DJ, et al.. Q J Med. 1981 Autumn;50(200):473-81.
• Thiébaud D, et al. Arch Intern Med. 1990 Oct;150(10):2125-8