Bone issues associated with malignancy
The Oncology Online Quality System (OOQS) provides up-to-date quality-controlled Edinburgh Cancer Centre documentation, including Clinical Management Guidelines by tumour group, SACT lists and procedures. OOQS includes guidelines for managing conditions associated with malignancy and treatment related side-effects.
- Refer to Guidelines for Treatment of hypercalcaemia on the OOQS page for cancer complications.
- Refer to Guidance on prevention of skeletal events in solid tumours in tumour specific Clinical management guidelines.
- Refer to local board guidance on prevention of skeletal events in multiple myeloma. In Lothian refer to the Haematology section of the NHS Lothian intranet.
OOQS: Tumour Site (intranet) OOQS: Systemic Anticancer Therapy (intranet) OOQS: SACT or SACT Toxicity (intranet) OOQS: Cancer Complications (intranet)
Adequate hydration to correct dehydration.
As per specialist. 3L over 24 hours 0.9% NaCl based on patient’s cardiac status.
As per specialist. 3L over 24 hours 0.9% NaCl based on patient’s cardiac status.
As per specialist. 3L over 24 hours 0.9% NaCl based on patient’s cardiac status.
As per specialist. 3L over 24 hours 0.9% NaCl based on patient’s cardiac status.
If GFR > 30ml/min and still hypercalcaemic after adequate hydration.
By intravenous infusion, 4mg as a single dose.
By intravenous infusion, 4mg as a single dose.
If GFR < 30ml/min after hydration, discuss with consultant and give pamidronate if benefit outweighs risk.
Adjust dose according to the level of the corrected calcium as follows:
Calcium < 3.0: 30mg
Calcium 3-3.5: 60mg
Calcium > 3.5: 90mg
If GFR <30ml/min then administer pamidronate at a rate of 20mg/hour (in at least 500ml 0.9% sodium chloride. Volume will depend on renal function).
Adjust dose according to the level of the corrected calcium as follows:
Calcium < 3.0: 30mg
Calcium 3-3.5: 60mg
Calcium > 3.5: 90mg
If GFR <30ml/min then administer pamidronate at a rate of 20mg/hour (in at least 500ml 0.9% sodium chloride. Volume will depend on renal function).
Adjust dose according to the level of the corrected calcium as follows:
Calcium < 3.0: 30mg
Calcium 3-3.5: 60mg
Calcium > 3.5: 90mg
If GFR <30ml/min then administer pamidronate at a rate of 20mg/hour (in at least 500ml 0.9% sodium chloride. Volume will depend on renal function).
Prescribing Notes:
- Patients with cancer most at risk of hypercalcaemia are those with known bone metastases or myeloma. 20% do not have bone metastases.
- Patients presenting with symptoms and/or signs suggestive of hypercalcaemia should have serum calcium and albumin checked. Symptoms include polydipsia, polyuria, confusion, constipation, anorexia.
- The decision to treat is based on the corrected serum calcium level:
- Corrected serum calcium = actual serum calcium + {(40- serum albumin g/L) x 0.02}
- Review medication affecting renal function (e.g. NSAIDs, diuretics, ACE-inhibitors) and consider stopping or withholding.
- Check U+E in 3-4 days (note that it can take up to 7 days for the full effects of bisphosphonate therapy to manifest). If corrected serum calcium has not returned to reference range, discuss future management with the consultant.
- Renal function, electrolytes, calcium and phosphate should be monitored during treatment with bisphosphonates.
- Doses of bisphosphonates should be adjusted in renal impairment.
- Osteonecrosis of the jaw has been reported in patients with cancer receiving treatment regimens including bisphosphonates. Many of these patients were also receiving chemotherapy and corticosteroids. A dental examination with appropriate preventive dentistry should be made prior to treatment with bisphosphonates in patients with concomitant risk factors (e.g. cancer, chemotherapy, corticosteroids, poor oral hygiene). While on treatment, these patients should avoid invasive dental procedures if possible.
History Notes
01/03/2023
East Region Formulary content agreed.