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Ministry of Health King Saud Medical city Quality Management & Patient Safety Adminisitalf on Riyadh. Kingdom at Saud Arabia Clinical Practice Guidelines ICSNIC
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Title (^) 1 Protocol for the Diagnosis and Management of Malignancy i Related Nypercalcemia I
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Initiating , Oncology Department Deportment/Committee: i Specialty: âI Oncology Guideline Category: i Assessment, diagnostic and management Applies to:. Oncologists, physicians ICD 10: E83.
introclucHon/Abslract
Hypercalcemia is relatively common in parents with cancer, occurring in approximately 20 to 30 percent of cases. It is the most common cause of hypercalcemia in the inpatient setting.
The most common cancers associated with hypercalcemia are breast and lung cancer and multiple myeloma.
Operational definition:
Hypercalcemb is defined as a corrected serum calcium >2.60 mrino1/1. Corrected calcium >4 mmo1/1 is life-threatening & requires URGENT treatment. Corrected calcium (mmogl) total calcium (mmold.) + (0.02 x [40- albumin In gill)
Guideline Scope and Purpose:
Scope: The guideline will cover the diagnosis and management of all admitted outpatient and emergency cases
Purpose: To diagnose, assess and manage the malignancy related hyperockqemia
Target Population: Patients with elevated serum calcium levels related to malignancy.
NOTE: If parent has hYPercalcernia and is not known to have cancer, or they have cancer but it is not known to be metastatic, seek advice from Endocrinologist regarding investigation and management.
S. (^) Guideline specific Interventions and practices and recommendations:
CPG Protocol/Pail-way code: Protocol / DMMH/098 Fife ii e MAY 202Revision Date3 0 APR
Ministry of Mean King Saud Medical City Quality Management s Patient Safely Administration Riyadh. Kingdom of Saudi Arabia Clinical Practice Guidelines 10111C^
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rUNICM MANIFESTATIONS:
(bones, stones, abdominal groans, and psychic moans") General Intravascular volume contraction, weight loss, anoreda. pruritus, increased thirst Neurologic Lethargy, hYPOreflexia, confusion. psychosis. seizure, drowsiness, coma Musculoskeletal Muscle weakness. Bone pain
Gastrointestinal Anorexia. nausea, vomiting, constipation, obstipation, Flew
Renal Polyuria, Polydipsia. Nephrolithiasis, Nephrocolcinosis, Distal renal tubular acidosis, Nephrogenic diabetes insipidus, Acute and chronic renal insufficiency Cardiac Bradycardia, prolonged P-R interval, shortened GI-T interval, wide 1-waves, atrial/ventricular arrhythmias, Hypertension.
DIAGNOSIS and ASSESSMENT Measure serum calcium, phosphate, creafinine, and Albumin. Serum PTH. Perform EKG Measure blood pressure and pulse lying and standing (after I minute) to determine any orthostatic changes reflecting intravascular blood volume Observe jugular venous pressure Confirm corrected serum calcium concentration Measurement of serum ionized calcium (when there is doubt about validity of measurement of total calcium) Note: Low or below normal serum phosphate may be associated with PTH like activity or may reflect concurrent primary hypexparathyroldism.
cPo Protocol/Pathway code, Protocol / DMMH/098 Effective 03tv MAY (^207) D°1311 APR 2020
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Title al CPG/Protocol/Pathway: (^) Protocol for the Diagnosis and Management ol Malignancy
Related Hypercalcemia
Initiating Department/Commglee:
Oncology DeParlaent
Specialty: Oncology Guideline category. Assessment, diagnostic and management Applies to: Oncologists, physicians ICD 10: E83.
Determine urgency of treatment: Hospital based or Outpatient based:
Hospital based Management it
Outpatient based Management ff
Serum calcium greater than or equal to 3.0 mmol/L
Serum calcium less than 3.0 mmol/L
Altered level of consciousness Alert and oriented Nausea or vomiting (^) No significant nausea Intravascular volume contraction (^) Adequate intravascular volume Impaired renal function Normal renal function Cardiac arrhythmia (^) Stable cardiac rhythm Obsfipalion. ileus (^) Mild constipation No support at home Support at home Limited access to medical care Access to emergency care
Hospital based Management For all patients 1.1. Intravenous fluids: Isotonic saline (0.9% NaCI) at 300-400 ml/hr (assuming previously normal renal and cardiac function) to obtain euvolemic status. 1.2. Âą Furtnemide Use cautiously. only if volume overloaded).
For hypercalcemia greater than or equal to 4 mmold. 2.1. IM/SC Calcitonin: 4-8 unit/kg q 6h x 2 days PLUS 2.2.1V Zoledronic acid (started concurrently with calcitonin): 4 mg in 100 mL NS over 15 minutes (note: see 4(6) OR 2.3. Denosumab 120 mg SubQ
CPG Protocol/Pathway Code: Protocol / DMMH/098 Effective Date: Revision Dot 3 0 MAY 2018
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Title of CPC/Protocol/Pathway; Protocol for the Diagnosis and Management of Malignancy
Related Hypercalcemla
Initiating (^) Oncology Department Deparlmenl/Commlnee: Specially: (^) I Oncology Guideline CategOrY: Assessment, diagnostic and management Applies to: (^) Oncologists, Physicians ICD 10: 583.
3. For hypercalcemia greater than or equal to 3.5 mmol/L 3.1. IV Zoledronic acid 4 mg in 100 mL NS over 15 minutes Mote: see #6) OR 3.2, Denosumab 120 mg Sub 3. For hypercalcemia less than (^) 15 mmoin. with symptoms 4.1. IV Zoledronic acid 4 mg in 100 mL NS over 15 minutes Mote: see #6) OR 4.2. Denosumab 120 mg SubQ 5. Re-treatment 5.1. For Zoledronic acid. wait at least 7 days before considefing re-treatment. (Bisphosphonotes should not normally be given again within 3 weeks, as there is a risk of hypecolcoemia if given too soon. Consult the responsible oncologist for decision for re-treatment)
5.2. If Denasomab used, give an additional 120 mg on days 8 and 15 (after checking the corrected calcium level and approval of the responsible oncology consultant).
5.3. for those Patients who relapse after initial treatment, or require routine therapy to maintain normal serum calcium concentrations it is recommended that the same drug used initially be continued.
S. Zoledronic Acid Dose Modification for Renal Banal:in 6.1. In ase of abnormal renal function: Denosumab 120 mg SuloG) (preferred). OR 6.2. Single doses of Zoledronic acid should not exceed 4 mg and the duration of infusion should be no less than 15 minutes as follows:
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Algorithm for the Diagnosis and management of Malignancy Related HyperCakeTla Adjusted tmildynn >4 (^) !Immo! / L Is itre threaterung& rE uires URGENT treatIllent SionsandSymptornsoillypenakami⢠Polyuri⢠(^) alloPinta Constipation Pelyaripele Heuastiniamiling (^) ConlUsron SCRs. antythallas(awl
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Title of CPG/Protocol/Pathway: Protocol for the Diagnose and Management of Malignancy
Related Hypercalcemia
initiating Department/Committee:
Oncology Department
specialty. Oncology Guideline Category: Assessment, diagnostic and management Applies to: Oncologists physicians IGD 10. E83.
7 Protocol measures (Quality measures):
Number of patients managed appropriately for malignancy related Hypercalcemia as per protocol
8. Documentation (implementation tools)
Physician order form
9 Bibliographic Source(s).LIst at references
Minisola, Salvatore, et al. The diagnosis and management of hypercalcaernia." brri 350.8011 (2015): h2723.
Cancer: Principles and Practice of Oncology (4K ed) 1997 Devito s, Heilman S. Rosenberg S. ed. Vol 2 Section 3 Metabolic Emergencies: Hypercalcemia pp
zoledronic acid: Drug information, accessed online 6 Feb 2018, Lexicomp online. Hu, Mimi I., et al."Denosumab for treatment of hypercalcemia of malignancy." The Journal of Oinical Endocrinology & Metabolism 99.9 (2014): 3144-3152.
Van Roznak, Catherine, et at 'Role of Bone-Modifying Agents In Metastatic Breast Cancer: An American Society of Clinical Oncology-Cancer Care Ontario Focused Guideline Update: Journal of Clinical Oncology 35.35 can 7): 3978-3986.
10. Disclaimer Statement:
This protocol is for diagnosis and management of Malignancy Related Hypercatcemia and will never replace the clinical judgment of physician or individual needs.
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