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Hypercalcaemia of malignancy

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2 min synopsisUK scopeSources checked 27 Aug 2026Clinical review pending
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Severe symptomatic hypercalcaemia

Marked calcium elevation with dehydration, acute kidney injury, arrhythmia, severe weakness, delirium or coma can deteriorate rapidly. A value above 3.5 mmol/L is an emergency even when symptoms appear deceptively nonspecific.

Action: Use ABCDE assessment, obtain ECG and repeat or ionised calcium with renal and electrolyte tests, stop contributors and begin carefully monitored intravenous 0.9% sodium chloride. Seek acute oncology or endocrine advice for prompt antiresorptive treatment, calcitonin bridge or dialysis when fluid and kidney or cardiac constraints make standard care unsafe.

Synopsis

Recognise symptomatic malignant hypercalcaemia, confirm biologically meaningful calcium elevation, restore volume safely, select antiresorptive and mechanism-specific treatment, monitor delayed response and align recurrence prevention with prognosis and goals.

  • Suspect hypercalcaemia with new thirst, polyuria, dehydration, constipation, nausea, weakness, drowsiness or delirium, especially in breast, lung, renal, myeloma and advanced squamous cancers.
  • Severity depends on symptoms, speed of rise, renal function and ECG as well as the number; adjusted calcium above 3.5 mmol/L is a medical emergency.
  • First-line confirmation uses repeat adjusted calcium with albumin, or ionised calcium when albumin, acid-base state or critical illness makes correction unreliable.

Key red flags

Reduced consciousness, seizure, aspiration or rapidly progressive delirium indicates severe neurological involvement.

Severe symptomatic elevation

Adjusted calcium above 3.5 mmol/L, coma, arrhythmia, profound dehydration or acute kidney injury requires urgent monitored treatment.

Investigation priorities

01
Repeat adjusted and ionised calciumFirst step

Confirm true elevation with concurrent albumin and use ionised calcium when correction is unreliable because of albumin, pH or critical illness.

Management branches

Immediate correctionRestore volume and lower calcium safely

Hypercalcaemia is symptomatic, rapidly rising or above the severe threshold.

  1. Confirm calcium and albumin or ionised calcium, obtain ECG and renal-electrolyte baseline, stop contributing treatment and assess goals and escalation.
  2. Infuse 0.9% sodium chloride at an individual rate with frequent respiratory, fluid and urine review; treat genuine overload rather than routinely forcing diuresis.

Key medicines

Zoledronic acid after volume assessmentA usual adult tumour-hypercalcaemia dose is 4 mg intravenously as a single infusion over at least 15 minutes after adequate hydration; verify renal function, product criteria and local acute-oncology protocol before administration.
Pamidronate as an intravenous alternativeUse a single intravenous dose selected from 30 to 90 mg according to initial calcium and local protocol, infused slowly with particular attention to renal function and total treatment history.
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Sources and review status5 sources · checked 27 Aug 2026 · clinical review pending
Sources

Sources and review status

National guidance is shown before implementation-dependent detail. Typical adult dose examples remain subject to patient factors, contraindications and the live BNF or specialist protocol. Source check completed 27 Aug 2026; clinical approval remains outstanding.

Authoring stateRapid draftClinical stateAwaiting reviewJurisdictionUnited Kingdom