Management

The basic principles of management involve rehydration to restore glomerular function and the use of drugs to inhibit osteoclastic bone

Table 39.1 Symptoms and signs of hypercalcaemia

Symptoms

Signs

Gastrointestinal

Nausea

Vomiting

Anorexia

Constipation

Renal

Polyuria

Dehydration

Thirst

Uraemia

Hypercalciuria

Nephrocalcinosis

Neurological

Lethargy

Muscular weakness

Drowsiness

Stupor

Weakness

Confusion

Disorientation

Dysarthria

Visual disturbance

Diminished reflexes

Pain

resorption. Where possible, specific anti-tumour therapy should be instituted. Occasionally, the secretion of humoral factors by a primary tumour results in hypercalcaemia, and in such cases the serum level may be corrected by surgical removal of the tumour. Typically however, the malignancy is advanced and treatment is palliative.

Absorption of calcium from the gut is usually reduced in patients with malignant hypercalcaemia and, except for the rare patient with lymphoma (usually T cell) associated with raised levels of vitamin D metabolites. They should be encouraged to eat what they like, when they like, irrespective of the food's calcium content. Immobilization should be avoided where possible as this may precipitate hypercalcaemia, since the lack of weight-bearing induces increased osteo-clastic activity while reducing bone formation.

Dehydration is an inevitable feature of symptomatic hypercalcaemia and it is essential to rehydrate with 3-4 litres of 0.9% normal saline to restore glomerular function and increase urinary excretion of calcium. Rehydration will relieve many of the symptoms of hypercal-caemia but will rarely achieve total control.

Prior to the 1990s, specific treatment of hypercalcaemia relied mainly on the use of calcitonin and mithramycin as inhibitors of osteoclast action, but these have largely been superceded by bisphosphonates.

Corticosteroids have been widely used in the treatment of hypercalcaemia but, except in steroid-responsive tumours, add little to the response achieved by intravenous rehydration.

♦ Selective inhibitors of osteoclast activity

♦ Agent of choice in hypercalcaemia—pamidronate, clodronate

♦ Highly effective (90% normocalcaemia)

♦ Usually normocalaemic in 3-7 days

♦ Side-effects—transient fever, hypocalcaemia

♦ IV route needed in acute situation

♦ Later, oral maintenance therapy.

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