Oncologic Emergencies: Hypercalcemia of Malignancy

Question 1

Mild hypercalcemia (corrected)

Answer 1

10.5-11.9mg/dl

Question 2

Moderate hypercalcemia (corrected)

Answer 2

12-13.9mg/dl

Question 3

Severe hypercalcemia (corrected)

Answer 3

≥14mg/dl

Question 4

Hypercalcemia symptoms: renal

Answer 4

polyuria, polydipsia, dehydration, decreased GFR

Question 5

Hypercalcemia symptoms: GI

Answer 5

constipation, anorexia, N/V, acute pancreatitis (rare)

Question 6

Hypercalcemia symptoms: neurologic

Answer 6

lethargy, confusion, irritability, muscle weakness, seizure, stupor, coma

Question 7

Hypercalcemia symptoms: cardiac

Answer 7

shortened QT interval, widened T-wave, heart block, asystole, atrial and ventricular arrhythmia

Question 8

Goal of hypercalcemia of malignancy treatment

Answer 8

Treat underlying malignancy

Question 9

What kinds of medications do you hold that can worsen hypercalcemia

Answer 9

Vitamin D, calcium, thiazide diuretics

Question 10

Hypercalcemia of malignancy treatments

Answer 10

Hydration: NS +/- furosemide
Primary therapy: IV bisphosphonates, RANK-L inhibitors

Question 11

IV bisphosphonates used

Answer 11

Zoledronic acid, pamidronate

Question 12

Onset of IV bisphosphonates

Answer 12

48-72 hours, nadir in 4-7 days

Question 13

AEs of bisphosphonates

Answer 13

flu-like symptoms (premeditate with APAP), fever, arthralgias, nephrotoxicity, osteonecrosis of the jaw

Question 14

RANK-L inhibitor

Answer 14

Denosumab

Question 15

Denosumab onset

Answer 15

48-72 hours, nadir in 9-10 days

Question 16

Denosumab role in hypercalcemia of malignancy therapy

Answer 16

hypercalcemia refractory to bisphosphonates; use in patients with severe renal impairment

Question 17

Denosumab toxicity

Answer 17

Severe hypocalcemia, hypophosphatemia

Question 18

Secondary therapy for hypercalcemia of malignancy

Answer 18

Calcitonin, glucocorticoids, calcimimetics, dialysis

Question 19

Calcitonin onset

Answer 19

1-4 hours, peak in 12-24 hours

Question 20

Calcitonin counseling point

Answer 20

Limited to first 48 hours due to tachyphylaxis

Question 21

Glucocorticoid clinical pearl

Answer 21

Multiple myeloma is susceptible to steroids

Question 22

What are calcimimetics effective in?

Answer 22

parathyroid carcinoma or primary/secondary hyperparathyroidism