Hypercalcaemia is common in advanced cancer particularly breast cancer, lung cancer and myeloma.
- Mild hypercalcaemia is an adjusted serum calcium of greater than 2.6 but less than 3.00 mmol/L
- Moderate hypercalcaemia is an adjusted serum calcium of 3 to 3.5 mmol/L
- Severe hypercalcaemia is an adjusted serum calcium of greater than 3.5 mmol/L
Red Flags
- Serum adjusted calcium >3.0 mmol/L
- Onset of confusion or reduced consciousness
- Severe dehydration or acute kidney injury
- Active treatment is appropriate
Clinical Features
Symptoms often mimic those of advanced illness:
- Cognitive/neurological: confusion, drowsiness, fatigue
- Gastrointestinal: nausea, vomiting, constipation, anorexia
- Renal: polyuria, dehydration
- Musculoskeletal: worsening bone pain
Initial Approach to Treatment in the community
- Check adjusted serum calcium
- Review current medications (e.g. thiazides, calcium/vitamin D supplements)
- Discuss ceiling of care with patient/family as definitive treatment requires hospital admission
- Hydration: Encourage oral fluids, consider subcutaneous fluids if possible at home
- Steroids (e.g. dexamethasone 8mg) may be helpul in certain malignancies (e.g. lymphoma, myeloma)
- Symptom control: Antiemetics, laxatives, and delirium management as needed
Specialist input from secondary care/ inpatient palliative care
If condition is deteriorating despite above measures and active treatment is appropriate
Bisphosphonates (e.g., IV zoledronic acid or pamidronate) are usually effective in reducing calcium in malignancy-related hypercalcaemia
Denosumab – via oncologists
When Not to Treat
In patients nearing end of life where symptoms are mild or treatment burden outweighs benefit, it may be appropriate to focus solely on comfort