Transcript NW Palliative care Emergencies

Palliative care Emergencies
Guidance for General Practice
Western Area
2. Hypercalcaemia
October 2014.
Western Trust Primary Palliative Care Team
Foyle Hospice Medical team
• This Guidance is based on :
• Guidance from Cumbria and Lancashire North
Palliative care. See http://www.gppalliativecare.co.uk/?c=clinical&a=hypercalcae
mia.
• NICE Guidance:
http://cks.nice.org.uk/hypercalcaemia#!scena
rio:2
What is it?
• A raised level of corrected* calcium in the blood.
• *TOTAL plasma calcium is the combination of
free, ionised calcium and protein-bound calcium.
If the albumin level is low, protein bound calcium
is low. This may mask a high concentration of
free, ionised calcium. Calcium is therefore
'corrected' for albumin level.
Calculating Corrected Calcium:WHSCT
lab
• Serum calcium plus
(40-serum albumin x 0.025)
• E.g. if albumin is 28, then add
• 40-28 x 0.025 = 0.3
Why is it important?
• 1. It may cause symptoms. These do not always relate
to the level of serum calcium.
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Common symptoms are:
•Polyuria, polydipsia
•Vomiting
•Constipation
•Tiredness and lethargy
•Muscle weakness
•Confusion
•Coma
Why is it important?
• 2. It may cause pain, or make existing pain
worse.
• 3. It may cause dehydration, coma and (if
untreated) cardiac arrest.
How common is it?
• •10-20% of all cancer patients
• •20-40% of patients with cancer of the
bronchus, breast or myeloma will have
hypercalcaemia
What sort of cancer produces hypercalcaemia?
• • Myeloma is the most likely tumour to produce
hypercalcaemia (a third of patients admitted to hospital).
• • Carcinoma of lung and breast account for over half the
cases seen.
• • Carcinoma of stomach and large bowel rarely produce
hypercalcaemia.
• Hypercalcaemia of malignancy is caused by the secretion of
a PTH-like substance by the tumour. Contrary to popular
belief, it can occur in the absence of bone metastases.
Conversely, patients can have widespread bone metastases
and remain normocalcaemic.
What is the significance of
hypercalcaemia?
• It usually indicates disseminated disease (74%).
95% of patients with breast cancer and
hypercalcaemia have disseminated disease. 61%
of patients with lung cancer and hypercalcaemia
have disseminated disease.
• There are only four cases in the world literature
of a cure in the presence of malignant
hypercalcaemia; Hypercalcaemia usually means a
very poor prognosis - 4/5 of patients die within a
year.
Treatment
• Treatment is aimed at improving wellbeing and symptoms for
symptomatic patients for weeks or even months. The treatment of
choice is an intravenous bisphosphonate infusion (Pamidronate).
Zoledronic acid is even more potent. Before treatment, the
following need to be considered:
• •Is the patient symptomatic or is the serum corrected calcium
>3mmol/l?
• •Is this the first episode? If so, an oncology opinion is
warranted. A change in anti-tumour therapy may be
indicated.
• •Is the patient's quality of life good (in their opinion)? - Is the
patient willing to undergo IV therapy/blood tests?
• •Will the treatment work? (What response was there to
previous treatment?)
Treatment
• Treatment is usually simple and well tolerated. Sometimes transient
flu-like symptoms occur which respond to oral Paracetemol. A
typical dosing schedule for Pamidronate is given below.
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Corrected Serum Calcium mmol/l Pamidronate dose (mg)
<3
symptomatic? If so treat (30-60mg)
3-3.5
30-60mg
3.5-4
60-90mg
>4
90mg
• The dose is usually made up in 500mls of N saline and given over
two hours. With appropriate supervision and training it can be given
in day case units, community hospitals or in the home if nursing
support is available.
Treatment
• It takes up to 3 days to start working and 5-7 days to exert
its maximum effect.
• Patients who are very symptomatic, clinically dehydrated or
with a calcium > 3.5 will need admitting for rehydration for
3 days while it takes effect.
• The dose can be repeated after a week if the initial
response is inadequate.
• Zoledronic acid 4mg is as effective as pamidronate 90mg,
can be given I/V over 5-10 minutes and response can last
up to five weeks. This makes it advantageous in a primary
care setting, but choice of bisphosphonate may depend on
local guidelines and protocols.
How long does treatment last?
• A single infusion will usually maintain normocalcaemia
for three to four weeks. Hypercalcaemia tends to recur.
• Consider monitoring the serum calcium weekly and
ensure the patient and family know the symptoms to
watch for.
• Pamidronate infusions can be repeated every three four weeks according to the serum calcium.
• There is no evidence that oral bisphosphonates prevent
further episodes of hypercalcaemia and they are poorly
tolerated.
Key Points
• •Hypercalcaemia of malignancy usually indicates
disseminated disease and a poor prognosis.
• •Anticipate hypercalcaemia in patients with myeloma,
carinoma of the lung and carcinoma of the breast.
• •Always check a serum calcium for patients with
unexplained vomiting, thirst, polyuria or confusion.
• •Treatment with intravenous bisphosphonates is
simple, effective and can give useful palliation.
• •Once hypercalcaemia has occurred, it may recur.
Patients should be aware of symptoms and have serum
corrected calcium monitored.
Sources of Advice/Guidance
• Foyle Hospice Community Palliative Care
Team: 02971351010
• Southern Sector NI Hospice Community
Palliative Care Team 02868621517
• For patients undergoing Oncology treatment:
0ncology 24 hour helpline: 02871 611289.
(manned by Oncology Nurse based at
Altnagelvin Sperrin Unit)