Hypercalcemia (PDQ®): Supportive care - Health Professional Information [NCI] - Management
Any acute severe exacerbation or development of new bone pain should be evaluated for the presence of a pathological fracture. Many health care facilities institute fracture precautions for patients with metastatic disease to the bone. These precautions include gentle handling when moving or transferring patients and fall-prevention strategies. Maximum mobility and weight-bearing exercises are desirable.
Supportive care in terminal stages typically consists of comfort measures for patients and their caregivers. Changes in mentation and behavior may be especially distressing to family members.
Supportive management of delirium, agitation, or changes in mental status is implemented in patients with hypercalcemia. Primary treatment of hypercalcemia and/or its underlying etiology eventually leads to the resolution of changes in mental status in most of these patients. Some patients present with clinically significant and distressing changes in mental status, agitation, or delirium that warrants management or control. (Refer to the PDQ summary on Delirium for more information.) Clinical experience supports the use of neuroleptic medications such as haloperidol (0.5–5.0 mg IV or by mouth 2–4 times a day) alone or in combination with benzodiazepines (e.g., 0.5–2.0 mg of lorazepam IV or by mouth 2–4 times a day) for the control of agitation and confusion. This enhances patient and family comfort and allows for easier institution of primary therapies. The use of benzodiazepines in these situations should be reserved for instances in which sedation (and not improvement in mental status) is the primary goal of the intervention.
The relationship between mental status and serum calcium levels is variable. Some patients will not manifest improvement in mental status until days to a week or more after serum calcium levels are in the normal range; others will display improvement before laboratory values catch up.
Many times, lethargy is a presenting symptom of hypercalcemia. Lethargic patients are often mistakenly believed by family (and sometimes by staff) to be depressed before the actual etiology of the mental-status changes becomes known. The differential diagnosis is generally straightforward in that many of these patients will lack the cognitive or ideational symptoms of a mood disorder (hopelessness, helplessness, anhedonia, guilt, worthlessness, or thoughts of suicide) and instead will appear mainly lethargic and apathetic; formal testing of mental status is likely to reveal cognitive deficits. This is an important distinction to be made, as the introduction of antidepressant drugs during an organic confusional episode can worsen confusion.
Management of hypercalcemia
- Correct dehydration due to calciuresis and vomiting with IV hydration using isotonic saline.
- Prevent or manage fluid overload with a diuretic such as furosemide, 20 mg to 40 mg every 12 hours.
- Treat hypercalcemia with one of the following agents:
- pamidronate, 60 to 90 mg IV over 2 to 24 hours.
- calcitonin, 4 IU/kg SC or IM every 12 hours.
- plicamycin, 25 to 30 μg/kg IV over 30 minutes.
- gallium nitrate, 200 mg/m2 per day IV over 24 hours for 5 consecutive days.
- Provide patient and family education:
- Signs and symptoms of hypercalcemia to report to the health care provider:
- Loss of appetite.
- Excessive thirst.
- Preventive measures:
- Maintain mobility.
- Ensure adequate hydration.
- Provide supportive care:
- Protect from injury.
- Prevent fractures.
- Manage related symptoms (e.g., nausea, vomiting, and constipation).
- Manage mental-status changes:
- Haloperidol, 0.5 to 5 mg IV or by mouth 2 to 4 times a day for agitation or confusion.
- Benzodiazepines such as lorazepam, 0.5 to 2 mg every 4 to 6 hours as needed for sedation.