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Hypercalcemia

Treatment

Prevention

Patients at risk of developing hypercalcemia may be the first to recognize its symptoms, such as fatigue. Measures to prevent hypercalcemia include drinking enough fluids, controlling nausea and vomiting, walking and being active, and cautious use or elimination of drugs that can contribute to the development of hypercalcemia or affect its treatment. Calcium in the diet should not be reduced or eliminated, however, because the body's absorption of calcium is reduced in patients with hypercalcemia.

Managing hypercalcemia

Fluids are given to treat dehydration. Medication is given to stop the breakdown of bone. The cancer causing the hypercalcemia should be treated effectively.

The severity of the hypercalcemia determines the amount of treatment necessary. Severe hypercalcemia should be treated immediately and aggressively. Less severe hypercalcemia should be treated according to the symptoms. Response to treatment is shown by the disappearance of the symptoms of hypercalcemia and a decrease in the level of calcium in the blood.

Mild hypercalcemia does not usually need to be treated aggressively. Patients with mild hypercalcemia and central nervous system symptoms are harder to treat. Younger patients are especially difficult to treat because they tolerate hypercalcemia better. Other causes of the central nervous system symptoms should be ruled out before deciding that they are caused by hypercalcemia alone.

Treatment for hypercalcemia can improve symptoms. Increased urination and thirst, central nervous system symptoms, nausea, vomiting, and constipation improve with treatment more easily than other symptoms, such as loss of appetite, and tiredness. Pain may be more easily controlled once calcium levels are normal. Effective therapy that lowers calcium usually improves symptoms, enhances the quality of life, and may allow the patient to leave the hospital.

After calcium levels return to normal, urine and blood should continue to be checked often to make sure the treatment is still working.

Mild hypercalcemia

Giving fluids by vein and observing the patient is an accepted treatment for patients with mild hypercalcemia (but no symptoms) and who also have cancer that responds well to anticancer treatment (such as lymphoma, breast cancer, ovarian cancer, head and neck cancers, or multiple myeloma). If the patient has symptoms, or has a cancer that is expected to respond slowly to treatment, then drugs to treat the hypercalcemia should be started. Other treatments should focus on controlling nausea, vomiting, and fever, encouraging continued activity, and limiting use of drugs that cause sleepiness.

Moderate to severe hypercalcemia

Replacing fluids is the first and most important step in treating moderate or severe hypercalcemia. Replacing fluids will not restore normal calcium levels in all patients, but it is still important to do first. The patient's mental state should improve, and nausea and vomiting should decrease within the first 24 hours, but this improvement is only temporary. If cancer therapy (surgery, radiation, or chemotherapy) is not able to be started immediately, then drugs to lower the calcium levels must be used to control the hypercalcemia.

Drugs that may help stop the breakdown of bone include calcitonin, plicamycin (mithramycin), bisphosphonates (etidronate, pamidronate, and clodronate), and gallium nitrate. Steroids and phosphate may also be used to treat hypercalcemia. Dialysis is used as a treatment for hypercalcemia in patients with kidney failure. Other drugs are currently being studied as possible treatments for hypercalcemia. Combinations of drugs may also be used.

Patient and family education

Because hypercalcemia affects quality of life and can be life-threatening if not treated, patients and their caregivers should be aware of the symptoms. They should also learn how to prevent hypercalcemia, what can make it worse, and when to see the doctor.

Supportive care

Even with improved treatment for hypercalcemia, many patients do not survive this complication of cancer. Only effective anticancer therapy improves the patient's chances for long-term survival.

Supportive care includes measures to provide the patient with protection from injury, prevention of fractures, and treatment of symptoms.

Treatment of symptoms is important, especially the prevention of accidental or self-inflicted injury if a patient is confused. Nausea, vomiting, and constipation may also need to be controlled until calcium levels go down. Broken bones may occur due to weakening, so patients need to be moved gently, and falling must be prevented. Activity and weight-bearing exercises should be encouraged. Any new bone pain should be reported so that it can be evaluated for possible fractures.

Supportive care to comfort terminally ill patients and their family members becomes necessary in the last stages of the disease. Changes in the patient's thinking and behavior may especially upset the family.

Psychosocial management

Usually, treatment of the hypercalcemia will eliminate delirium, agitation, or mental changes, but some patients may need other medications to treat these symptoms. (See the PDQ summary on Cognitive Disorders and Delirium for more information.) Mental changes may take some time to get better, even after calcium levels return to normal.

Lethargy (mental and physical sluggishness) is often a symptom of hypercalcemia. Family members (and sometimes medical staff) may think that the patient is depressed until the actual cause is determined. Most patients will not have symptoms of depression (such as hopelessness, helplessness, guilt, worthlessness, or thoughts of suicide) and instead will appear to be indifferent.

Patients and family members should report symptoms of hypercalcemia such as lethargy, fatigue, confusion, loss of appetite, nausea/vomiting, constipation, and excessive thirst to the health care provider.

Prognosis

Hypercalcemia usually develops as a late complication of cancer, and its appearance is very serious. However, it is not clear if death occurs due to a hypercalcemia crisis (uncontrolled or one that comes back and gets worse) or due to the advanced cancer.