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Elevated blood calcium level (Hypercalcemia)
Julie Schwenka, PharmD
University of California, San Francisco

Introduction
Diagnosis and Treatment
Drug Name Table
Supportive Care

Introduction
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Hypercalcemia (high levels of calcium in your blood) is the most common life threatening disorder that is associated with cancer. It occurs in 10 to 20% of cancer patients. Lung cancer, breast cancer and multiple myeloma are the most prevalent malignancies associated with hypercalcemia. The cause of hypercalcemia is when cancer spreads to or invades the bones and when malignant cells release certain factors that cause calcium to be released from the bone. This causes bones to break down faster than they are being rebuilt, resulting in an increase calcium release into the blood stream. Normally, your kidneys would eliminate excess calcium from your blood, but with hypercalcemia the kidneys cannot keep up with the elimination process. Some physical signs to look out for when your blood calcium is too high would be tiredness, confusion, unstable gait, constipation, decreased appetite, increase urination and bone pain. If hypercalcemia is not diagnosed it can lead to more serious complications like heart problems, convulsions and even coma. If you feel any of these symptoms or if your family members or friends are noticing that you are not walking steady or seem confused, you should make an appointment with your doctor immediately. Your doctor can check your blood to see if you are suffering from hypercalcemia.

Diagnosis and Treatment
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Mild Hypercalcemia (corrected total serum calcium < 12mg/dL) - Patients usually do not have any symptoms of hyercalcemia when the blood calcium levels are this low. The best option here is to stay well hydrated, exercise and your doctor should follow your blood calcium levels while you are undergoing treatment for your cancer.

Moderate to Severe Hypercalcemia (corrected total serum calcium > 12mg/dL) - Your doctor may prescribe some drugs (biphosphonates) to stabilize the bones and prevent hypercalcemia. Pamidronate (Aredia®) and zolendronic acid (Zometa®) are the preferred drugs for treating hypercalcemia and maintaining blood calcium levels. These drugs do not decrease calcium rapidly, so other measures may be needed to reduce calcium more quickly. This may mean that you may have to be admitted to a hospital for monitoring and drug therapy. This therapy includes a lot of intravenous fluid (usually a saline solution) along with a diuretic like furosemide (Lasix®). The diuretics should not be started however until you have been properly hydrated with the saline solution. Pamidronate or zolendronic acid may be used concurrently and then every month if needed. Sometimes a drug called calcitonin is used to help lower calcium until the biphosphonates start working (around 2 to 4 days). These drugs are not available in oral form so they must be given intravenously. Other medications that are used to treat hypercalcemia are etidronate, clodronate, plicamycin and gallium nitrate, however, they are not as effective, they have more side effects and they are not tolerated very well. Below is a table of the most effective and well-tolerated biphosphonates.

Drug Name Table
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Drug name Usual dose Side effects Approximate
AWP* Cost**
Pamidronate
(Aredia®)
60 to 90 mg IV every month infused over 2 to 4 hours Fever, bone pain $800/vial
Zolendronic acid
(Zometa®)
4mg IV every month infused over 15 minutes Fever, bone pain, flu Like symptoms $900/vial
Calcitonin
(Calcimar®)
4-8 units/kg IM or SQ every 12 hours Facial flushing, nausea, vomiting $30/400unit ampule

*Average Wholesale Price
**This price does not reflect other incurred costs (nursing, pharmacy compounding, office visit).

Supportive Care
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Some of the symptoms of hypercalcemia can worsen hypercalcemia. Symptoms like nausea, vomiting or constipation should be treated and managed immediately. You should stay drink a lot of fluids, have your doctor check your blood periodically and let your friends and family know of the signs and symptoms of hypercalcemia (fatigue, confusion, loss of appetite, nausea, vomiting and diarrhea). Maximum mobility and weight-bearing exercises are desirable. Move slowly when rising or laying down to prevent a fall that can lead to a fracture. Notify your doctor if you notice any new bone pain, it may be a new fracture.



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First appeared August 3, 2003; updated September 30, 2004