Palliative Care Guidelines
Jimmy S Bilimoria Foundation



Hypercalcaemia is the commonest life-threatening metabolic disorder associated with cancer. It produces several distressing symptoms, and management of hypercalcaemia alleviates the symptoms. Hypercalcaemia is defined as serum calcium (corrected) greater than 2.6mmol/L 0r 10.5mg/dL.

The incidence varies with the underlying malignancy, being most common in multiple myeloma, breast cancer and squamous cell lung cancer. It can occur even in the absence of bone metastasis.


  • Assessment must determine the underlying cause, effectiveness of treatment and impact on quality of life for the patient and their family (refer to the Guideline – Symptom Assessment
  • Symptoms and signs of Hypercalcaemia
    • General – dehydration, polydipsia, polyuria, pruritis
    • Neurological – fatigue, lethargy, confusion, myopathy, hyporeflexia, seizures, psychosis and coma
    • Gastrointestinal – anorexia, nausea, vomiting, weight loss, constipation, and ileus
    • Musculoskeletal – muscle, bone pain
    • Cardiac – shortened Q-T interval, prolonged P-R interval, wide T waves, ventricular and atrial arrhythmias and bradycardia


  • Questions to ask before managing hypercalcaemia
    • Is this the first episode and if not, what is the interval since the previous episode?
    • What is the problem?
    • Can it be reversed?
    • What is the goal of care?
    • Is the treatment appropriate?
    • What are the patient’s/carer’s wishes?
    • What effect will the relief of symptoms have on the overall general condition?
    • Will active treatment improve the quality of life?
  • Investigations (when appropriate)
    • Serum urea, electrolytes, albumin, and calcium
    • Calculate corrected calcium concentration
      • Corrected calcium (mmol/L) = Measured Calcium + ([40 – Serum albumin g/L] x 0.02mmol/L)
      • or
      • Corrected calcium (mg/dl) = Measured total serum calcium (mg/dL) + ([4.0-serum albumin g/dL] x 0.8)
  • Refer the patient to hospital if treatment of hypercalcaemia is appropriate
  • Consider symptom management only, if treatment of hypercalcaemia is not warranted or if the patient has advanced disease with poor prognosis
  • Management
    • Stop any drugs that can contribute to/ worsen hypercalcemia (thiazide diuretics, oral calcium supplements, calcitriol, antacids)
    • Urgent treatment is needed, if serum calcium level is 4mmol/L or 16mg/dl and above
    • Rehydrate with intravenous fluids 2 – 3L of fluid (0.9% saline)
    • Volume and rate depend on clinical and cardiovascular status and concentrations of urea and electrolytes
    • After a minimum of 2L of intravenous fluids give bisphosphonate infusion
      • Zoledronic acid 4mg in 100ml normal saline IV over 15 minutes
    • Dental clearance is mandatory before starting bisphosphonates, except in an emergency or acute setting
    • The dosage of bisphosphonates should be adjusted for decreased renal function
    • Bisphosphonates can produce flu-like symptoms
    • Measure concentrations of urea and electrolytes at daily intervals and give intravenous fluids as necessary
    • Normalisation of serum calcium takes 3-5 days
    • Do not measure serum calcium for at least 48 hours after rehydration as it may rise transiently immediately after treatment
    • Patients with repeated episodes or refractory hypercalcaemia should be referred to the care of the oncologist
  • Prevention of recurrent hypercalcaemia
    • Oncological treatment as appropriate
    • Monitor serum calcium levels and consider continuing bisphosphonates monthly


  • Bower, M., Robinson, L., Cox, S. (2015). Endocrine and metabolic complications of advanced cancer. Oxford Textbook of Palliative Medicine (pp. 906-918)
  • Falk, S., Reid, C. (2006). Emergencies. ABC of Palliative Care (pp. 40-43)
  • Kovacs, C., MacDonald, S.M., Chik, C., Bruera, E. Hypercalcemia of Malignancy in the Palliative Care Patient: A Treatment Strategy. Journal of Pain and Symptom Management. (1995); 10(3): 224-232
  • Medscape – Hypocalcemia Differential Diagnoses. Retrieved online from on 4 January 2019

Palliative Care Guidelines