# Hypercalcaemia of malignancy: assessment, intravenous fluids, bisphosphonate or denosumab

Source: https://onco.cc/protocols/hypercalcaemia-of-malignancy-management/  
OnCo record `hypercalcaemia-of-malignancy-management` (Protocol). Data CC BY-NC 4.0, attribute "Data from OnCo (onco.cc)"; commercial use needs a licence.

## TL;DR

Some cancers raise the calcium level in the blood. It causes thirst, passing a lot of urine, constipation, sickness, tiredness and confusion, and can be dangerous. A blood test confirms it. Treatment is a drip of fluid, then a medicine that stops calcium leaving the bones (a bisphosphonate such as zoledronic acid, or denosumab), alongside treatment of the cancer itself.

## Summary

Society for Endocrinology 2016: measure calcium adjusted for albumin. Under 3.0 mmol/L is often asymptomatic; 3.0 to 3.5 usually needs prompt treatment; over 3.5 needs urgent correction for the risk of dysrhythmia and coma. Check phosphate, PTH, urea and electrolytes and an ECG for a short QT; high calcium with a low PTH points to malignancy. Review drugs and supplements. Rehydrate with intravenous 0.9% saline, 4 to 6 L over 24 hours, watching for fluid overload in the elderly or with renal impairment; loop diuretics do not lower calcium and are only for overload. Then an intravenous bisphosphonate: zoledronic acid 4 mg over 15 minutes, pamidronate 30 to 90 mg or ibandronic acid 2 to 4 mg, more slowly and at reduced dose in renal impairment; the calcium nadir comes at 2 to 4 days. Prednisolone 40 mg daily for lymphoma and other calcitriol-driven causes. Denosumab, calcitonin and calcimimetics under specialist supervision.

Endocrine Society 2023 (GRADE): treat with denosumab or an intravenous bisphosphonate (strong recommendation); suggests denosumab rather than an intravenous bisphosphonate, calcitonin with a bisphosphonate or denosumab for severe hypercalcaemia, denosumab for refractory or recurrent cases despite bisphosphonate, an antiresorptive added to glucocorticoids for calcitriol-driven tumours, and a calcimimetic or antiresorptive for parathyroid carcinoma (all conditional, low certainty). Treating the cancer is what controls hypercalcaemia and prevents recurrence.

## Fields

- Kind: Protocol
- Last checked: 2026-11-11
- Also known as: malignant hypercalcaemia; hypercalcemia of malignancy treatment; HCM; high calcium in cancer; cancer-related hypercalcaemia
- Tags: protocol; acute-oncology; oncological-emergency; metabolic

## Connected records

- drugs: [Cinacalcet](https://onco.cc/drugs/cinacalcet/), [Denosumab](https://onco.cc/drugs/denosumab/), [Ibandronic acid](https://onco.cc/drugs/ibandronic-acid/), [Pamidronate](https://onco.cc/drugs/pamidronate/), [Zoledronic acid](https://onco.cc/drugs/zoledronic-acid/)
- terms: [Bone metastases and skeletal-related events](https://onco.cc/terms/bone-metastases/)

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