Bone Modifying Agents

Question 1

What are the mild symptoms of hypercalcemia?

Answer 1

• polyuria
• polydipsia
• constipation
• anorexia
• fatigue

Question 2

What are the moderate hypercalcemia symptoms?

Answer 2

• dehydration
• N/V
• lethargy
• confusion
• muscle weakness
• loss of deep tendon reflexes
• shortened QT
• widened T wave

Question 3

What are the severe hypercalcemia symptoms?

Answer 3

• decreased GFR
• nephrocalcinosis
• seizures
• stupor
• coma
• heart block
• arrythmias
• asystole

Question 4

What is a normal calcium range?

Answer 4

8.5-10 mg/dL

Question 5

How is corrected calcium calculated?

Answer 5

Serum Calcium + 0.8 (4 - Serum albumin)

Question 6

What are the lab value ranges for mild, moderate, and severe hypercalcemia?

Answer 6

• mild < 12 mg/dL
• moderate 12-14 mg/dL
• severe > 14 mg/dL

Question 7

What are the treatment options for asymptomatic or mild hypercalcemia symptoms?

Answer 7

• hydration
• d/c meds that increase Ca or decrease renal blood flow
• repeat Ca in 4 weeks

Question 8

What are the treatment options for moderate symptoms?

still mild labs (10-12)

Answer 8

• hydration with NS (200-400mL/hr)
• bisphosphonates (zoledronic acid)

Question 9

What are the treatment options for severe hypercalcemia?

Answer 9

• 200 mL/hr
• zoledronic acid
• calcitonin (not great)

Question 10

What is the main treatment option for refractory hypercalcemia?

Answer 10

denosumab

RANK-L inhibitor

Question 11

What are the treatment options for bone metastases?

goal –> palliation of symptoms

Answer 11

• radiation
• chemotherapy
• bisphosphonates
• RANK-L inhibitors
• radioisotopes

Question 12

What is the difference between the administration of pamidronate and zoledronic acid?

Answer 12

• pamidronate is infused over 2 hours
• zoledronic acid is infused over 15 minutes
• both need renal adjustments

Question 13

When are renal adjustments for pamidronate and zoledronic acid unnecessary?

Answer 13

hypercalcemia of malignancy

still dose adjust for skeletal related events

Question 14

What should the bisphosphonates be supplemented with?

Answer 14

• calcium
• vitamin D

Question 15

What RANK-ligand inhibitor is used?

Answer 15

denosumab

no renal dose adjustments

Question 16

What is the adverse effect of concern with the bone modifying agents?

Answer 16

osteonecrosis of jaw