A 56-year-old woman with known metastatic breast cancer presents to A&E with a calcium concentration of 3.22 mmol/l. Which of the following is the most appropriate initial management?
1. Intravenous hydrocortisone
2. Intravenous infusion of 0.9% sodium chloride (‘normal saline’)
3. Intravenous infusion of sodium phosphate
4. Oral bisphosphonate
5. Oral thiazide diuretic
Correct Answer 2
Intravenous infusion of 0.9% sodium chloride (‘normal saline’)0 The priority in symptomatic hypercalcaemia is to rehydrate the patient and establish a diuresis. ‘Normal saline’ is the fluid of choice. Bisphosphonates are effective, but must be given intravenously to have a rapid effect. A diuretic be helpful once the patient has been rehydrated, but this should be a loop diuretic, which increase calcium excretion, not a thiazide, as these reduce it. Corticosteroids occasionally be helpful but are not firstline treatment. Sodium phosphate infusion is dangerous: it lowers the calcium concentration rapidly, but risks causing metastatic calcification.