Confused topics thread...

[VCorp]

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I'm currently doing Endocrinology and reading MTB:IM and MTB:CKand MTB: 3 for my preparation. I'm a bit confused on the treatment of hypercalcemia. I know the best initial therapy is NS at high volumes. Can add furosemide if pt isn't producing sufficient urine. Here's where I'm confused...

if calcium is still high, do we add bisphosphonates or go with calcitonin? The latter acts faster than the former. However MTB:CK has bisphosphonates listed as the second treatment where as MTB:IM says "if calcium level is still very high after saline infusion, the most appropriate next step in management is calcitonin."

the sample question from MTB:CK uses NS first followed by Bisphosphonates 2nd and uses calcitonin as a third line agent.

 

[usmleswot]

Source UpToDate

Severe hypercalcemia — Patients with calcium >14 mg/dL (3.5 mmol/L) require more aggressive therapy. The acute therapy of such patients consists of a three-pronged approach [1-3]:

●Volume expansion with isotonic saline at an initial rate of 200 to 300 mL/hour that is then adjusted to maintain the urine output at 100 to 150 mL/hour. (See 'Saline hydration' below.)

The administration of calcitonin plus saline should result in substantial reduction in serum calcium concentrations within 12 to 48 hours. The bisphosphonate will be effective by the second to fourth day, thereby maintaining control of the hypercalcemia.

In the absence of renal failure or heart failure, loop diuretic therapy to directly increase calcium excretion is not recommended because of potential complications and the availability of drugs that inhibit bone resorption, which is primarily responsible for the hypercalcemia.

●Administration of salmon calcitonin (4 international units/kg) and repeat measurement of serum calcium in several hours. If a hypocalcemic response is noted, then the patient is calcitonin-sensitive and the calcitonin can be repeated every 6 to 12 hours (4 to 8 international units/kg). We typically administer calcitonin (along with a bisphosphonate) in patients with calcium >14 mg/dL who are also symptomatic. (See 'Calcitonin' below.)

●The concurrent administration of zoledronic acid (ZA; 4 mg intravenously [IV] over 15 minutes) or pamidronate (60 to 90 mg over two hours), preferably ZA, because it is superior to pamidronate in reversing hypercalcemia related to malignancy. (See 'Bisphosphonates' below.)

 

[Jambalayajonny]

EDIT: The user I had replied to got banned for spamming, but I can't delete my post now.