Today we discussed an interesting case of a patient who presented with right shoulder and generalized weakness, found to have epigastric tenderness, elevated lipase, and hypercalcemia, ultimately diagnosed with diffuse large B-cell lymphoma with bony involvement with bony involvement leading to severe hypercalcemia and resultant pancreatitis.
The management of hypercalcemia is dependent on the severity and whether or not the patient is symptomatic. That is, acute management is generally recommended if the serum Ca is greater than 14 or if it is greater than 12 and the patient is symptomatic (recall your stones, groans, moans, bones, and psychiatric overtones).
Asymptomatic patients with mild hypercalcemia can be advised to avoid factors that exacerbate hypercalcemia (such as excessive supplementation, thiazides, lithium, volume depletion, inactivity).
Acute management consists of:
1) Saline hydration: initial rate of 200 to 300 mL/hour, adjusted to maintain the urine output at 100 to 150 mL/hour. This increases calcium excretion and replaces intravascular volume. Consider adding a loop diuretic only in patients with heart failure or renal insufficiency to avoid volume overload.
2) Consider using calcitonin if calcium >14 who are symptomatic, however, keep in mind significant tachyphylaxis with this drug (usually only effective 2 days).
3) Longer term control:
- For patients with excessive bone resorption (malignancy, etc), consider giving a bisphosphonate: pamidronate or zoledronic acid. Denosumab could be considered as an alternative in patients that have severe renal impairment.
- Glucocorticoids are effective in treating hypercalcemia due to some lymphomas, sarcoid, or other granulomatous diseases.
4) Dialysis is typically reserved for patients with severe hypercalcemia.