Bisphosphonates for hypercalcaemia associated with cancer

Minisola, 2015

After initial intravenous rehydration, consider a bisphosphonate for patients with hypercalcaemia associated with cancer who have:

  • a serum total calcium concentration corrected for albumin of 3.0 mmol/L or higher
  • symptoms and a serum total calcium concentration corrected for albumin between 2.6 mmol/L and 3.0 mmol/L).

It is unclear whether bisphosphonate therapy is beneficial for asymptomatic patients with a serum total calcium concentration corrected for albumin less than 3.0 mmol/L.

Rehydrate patients before using a bisphosphonate; bisphosphonate use in patients who are dehydrated can lead to kidney injury due to deposition of calcium complexes in the kidney.

Note: Patients must be well hydrated before receiving bisphosphonate therapy.

If a bisphosphonate is indicated for acute treatment of hypercalcaemia associated with cancer, use:

1pamidronate 30 to 90 mg intravenously, as a single dose given over 4 hours pamidronate

OR

1zoledronic acid 4 mg intravenously, as a single dose given over at least 15 minutes. zoledronic acid

The bisphosphonate infusion can cause transient influenza-like symptoms. This most often occurs after the first dose, and is less likely to occur with subsequent doses. Paracetamol can reduce the severity of the reaction when taken before, and for several days after, the infusion.

For patients with kidney impairment, bisphosphonates may be contraindicated or dose adjustments may be required; see product information for detail.

When bisphosphonate therapy is effective, the serum calcium concentration usually starts falling within 3 to 4 days; with the maximum effect at 4 to 7 days. The duration of effect is between 2 to 4 weeks. Consider repeating the dose if hypercalcaemia recurs and treatment is clinically appropriate and desired by the patientAustralian Medicines Handbook (AMH), 2022Wilcock A, 2020.

If bisphosphonate therapy is ineffective, seek expert advice.

Although dental assessment is recommended before starting bisphosphonate therapyColeman, 2020, the burden of assessment is likely to outweigh the risk of developing osteonecrosis of the jaw in patients with a poor prognosis (eg weeks)Guise, 2022. For information on skeletal adverse effects of bisphosphonates, including osteonecrosis of the jaw, see the Bone and Metabolism guidelines.