Temporary measures

After taking account of the patient's cardiac and renal function, the following measures may be employed selectively:

• Physiological saline solution is important, firstly to correct sodium and water deficit and secondly to promote sodium-linked calcium diuresis in the proximal renal tubule. Initially, 0.9% saline 500 ml should be given i.v. every 4-6 h for

2-3 days and continued at a rate of 21/day until plasma calcium falls below 3.0 mmol/1 and the oral intake is adequate. The regimen requires careful attention to fluid and electrolyte balance, including potassium. Furosemide may be added to the regimen once salt depletion has been corrected.

• Bisphosphonates (see later). Pamidronate5 is infused according to the schedule in Table 38.1; it is active in a wide variety of hypercalcaemic disorders. Fall in serum calcium begins in 1-2 d, reaches a nadir in 5-6 d and lasts 20-30 d. Etidronate may be given i.v. in hypercalcaemia of malignant disease. It acts in 1-2 d and a dose lasts 3—4 weeks; it may also provide benefit for neoplastic metastatic disease in bone. Clodronate (oral or i.v.) or zoledonic acid (i.v.) are alternatives.

• Calcitonin (see below). When the hypercalcaemia is at least partly due to mobilisation from bone, calcitonin can be used to inhibit bone resorption, and it may enhance urinary excretion of calcium. The effect develops in a few hours, and responsiveness may be lost over a few days (but may sometimes be restored by an adrenal steroid).

• An adrenocortical steroid, e.g. prednisolone 20-40 mg/d orally, is effective in particular situations; it reduces the hypercalcaemia of vitamin D intoxication (which is due to excessive intestinal absorption of calcium) and of sarcoidosis (principally by its disease-modifying effect). Steroid may be effective in the hypercalcaemia of malignancy where the disease itself is responsive, e.g. myeloma of lymphoma. Most patients with hyperparathyroidism do not respond.

TABLE 38.1 Treatment of hypercalcaemia with disodium pamidronate

Calcium (mmol/1)

Pamidronate (mg)

<3.0 3 0 3 5 3 5 -4 0 >4.0

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