Medications used to treat hypercalcemia

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Some notes:

Fluids (normal saline) are the first-line treatment for hypercalcemia!

Cinacalcet (brand name: Sensipar) is used for hyperparathyroidism, whether caused by primary hyperparathyroidism or that related to CKD.

Calcitonin is used most often for moderate-severe hypercalcemia (such as in emergent situations when a patient with multiple myeloma comes in with symptomatic hypercalcemia), Paget disease, and postmenopausal osteoporosis. When being used for emergent situations, note that onset of action is ~2 hours and the effect lasts for 6-8 hours. It comes in injection and subcutaneous forms. It also comes in an intranasal form; the pharmacokinetics of that are highly variable/not reliable, but it’s much cheaper.

Bisphosphonates are a class of medication, and can be used for a wide range of indications including moderate-severe hypercalcemia, osteoporosis, adjuvant treatment for aromatase inhibitor-induced osteoporosis (in breast cancer patients), bone metastases, Paget disease, and osteogenesis imperfecta. In acute hypercalcemia, bisphosphonates (usually zoledronic acid or Zometa) are more potent than calcitonin, but take longer to work, reaching max efficacy in 2-4 days. Bisphosphonates are renally cleared so must be used with caution–and may even be contraindicated–in patients with CKD.

Not pictured is denosumab, a RANK-ligand inhibitor that increases bone mineralization and is used to treat osteoporosis. It is not traditionally used to treat hypercalcemia, and there are no formal guidelines on its dosing to treat hypercalcemia, but there are case reports of its use. Unlike bisphosphonates, it is not renally cleared so there are no restrictions for patients with CKD.


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