• Check serum concentration of urea, electrolytes, albumin, and calcium
• Calculate corrected calcium concentration
• Corrected Ca = measured Ca+(40-albumin) X 0.02 mmol/1
• Corrected calcium value is used for decisions about treatment
• Rehydrate with intravenous fluid (0.9% saline)
• Amount and rate depends on clinical and cardiovascular status and concentrations of urea and electrolytes
• After a minimum of 2 L of intravenous fluids give bisphosphonate infusion
Disodium pamidronate 90 mg over 2 hours or Sodium clodronate 1500 mg over 4 hours or Zoledronic acid 4 mg over 15 minutes
• Measure concentrations of urea and electrolytes at daily intervals and give intravenous fluids as necessary
Normalisation of serum calcium takes 3-5 days
Do not measure serum calcium for at least 48 hours after rehydration as it may rise transiently immediately after treatment
• Prevent recurrence of symptoms
Treat underlying malignancy if possible or
Consider maintenance treatment with bisphosphonates and monitor serum calcium every three weeks or
Monitor serum calcium every three weeks or less if the patient has symptoms, and repeat bisphosphonate infusion as appropriate considered.
Maintenance intravenous bisphosphonates may be administered at a day centre or outpatient department. Oral preparations have the disadvantages of being poorly absorbed and have to be taken at least an hour before or after food. A recent systematic review suggests there is more evidence to support the intravenous route.
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