Treatment of hypercalcemia in adults

Intervention	Mode of action	Onset of action	Duration of action
Isotonic saline hydration	Restores intravascular volume Increases urinary calcium excretion	Hours	During infusion
Calcitonin	Inhibits bone resorption via interference with osteoclast function Promotes urinary calcium excretion	4 to 6 hours	48 hours^*
Bisphosphonates	Inhibit bone resorption via interference with osteoclast recruitment and function	24 to 72 hours	2 to 4 weeks
Loop diuretics^¶	Increase urinary calcium excretion via inhibition of calcium reabsorption in the loop of Henle	Hours	During therapy
Glucocorticoids	Decrease intestinal calcium absorption Decrease 1,25-dihydroxyvitamin D production by activated mononuclear cells in patients with granulomatous diseases or lymphoma	2 to 5 days	Variation duration of effect (days to weeks)
Denosumab	Inhibits bone resorption via inhibition of RANKL	4 to 10 days	4 to 15 weeks
Calcimimetics	Calcium-sensing receptor agonists, reduces PTH (parathyroid carcinoma, secondary hyperparathyroidism in CKD)	2 to 3 days	During therapy
Dialysis	Removes calcium, a low or no calcium dialysate should be used	Hours	Reduction of calcium during dialysis

CKD: chronic kidney disease; PTH: parathyroid hormone; RANKL: receptor activator of nuclear factor kappa-B ligand.

* The efficacy of calcitonin is limited to the first 48 hours, even with repeated doses, due to the development of tachyphylaxis.

¶ Loop diuretics should not be used routinely. However, in patients with kidney function impairment or heart failure, judicious use of loop diuretics may be required to prevent fluid overload during saline hydration.

Data from: Shane E, Dinaz I. Hypercalcemia: Pathogenesis, clinical manifestations, differential diagnosis, and management. In: Primer on the Metabolic Bone Diseases and Disorders of Mineral Metabolism (Sixth Edition). American Society of Bone and Mineral Research 2006; 179.

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Treatment of hypercalcemia in adults