Treatments of Hypercalcaemia
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Transcript Treatments of Hypercalcaemia
End of Life Care
Dr Anant Sachdev
GPSI Palliative Medicine
07976 608871
[email protected]
Learning objectives
Urological Cancer symptoms in End of
Life
Identify those at risk from the following 2
serious clinical scenarios
Understand treatment options
Refer appropriately
General principles
Symptoms
Pain
• Malaise, Fatigue & Cachexia
• GI: Poor appetite, nausea
• Weight loss
• Bleeding
• Incontinence
• Delirium
• Spinal Cord Compression
• Hypercalcaemia
•
Malignant spinal cord
compression
First
contact is usually
primary health care team!
Common
Significant impact on QOL and survival
Requires rapid decision making
Incidence
5% of all cancers in final 2 years
Presenting feature
ACUP, NHL, myeloma and lung
Decreases with age, but 90% are >50yrs
Depends on primary site
60% are lung, prostate or breast
NHL, Multiple myeloma and renal (510%)
Colorectal, ACUP and sarcomas
Pathophysiology
Vertebral body mass – anterior
compression
Vertebral body collapse
Direct tumour growth through vertebral
neural foramen (lymphoma)
Metastases in epidural space (rare)
Clinical features
Localisation
60-80% thoracic spine
15-30% lumbosacral
<10% cervical
50% have more than 1 level
Clinical features
Pain – early sign
Up to 95% for 8/52
localised then radicular
Worse when
recumbent
valsalva manoevre
Neck flexion/SLR
Motor deficits – late sign
60-85% weakness at diagnosis
2/3 non ambulatory at diagnosis
Thoracic>lumbosacral
Clinical features
Sensory deficits – late sign
40-90% at diagnosis
Sensory level 1-5 segments below lesion
Lhermitte’s sign
Autonomic deficits – late sign
Urinary retention most common.
50% catheter dependent at diagnosis.
Unlikely to be an isolated sign.
Investigation
Plain Xray
False negative 17%
Bone scan
Back pain + negative bone scan & plain xray unlikely to have
SCC
CT Myelography
MRI
Sensitivity 93%, specificity 97%
Diagnostic accuracy 95%
Multi level common therefore image entire spine
Spinal Cord Compression
Treatment
Corticosteroids
8mg BD (morning and lunchtime) and PPI cover
Random daily BMs
Bed rest and pressure area care
Bowel care
RT (early as poss)
1# for pain mgt if no poss of recovery;
5# for treatment
Surgery
Early rehab
Recurrent Spinal Cord Compression
10% pt will develop local recurrence
25-50% pts surviving > 1 yr will
experience local relapse.
Mgt – surgery (may be inappropriate); Reirradiation; supportive and palliative care
Spinal Cord Compression
Prognosis
Median survival is 3-6 months
If ambulatory pre compression 8-10 months
Non-ambulatory pre compression 2-4 months
Primary tumour myeloma / lymphoma – 6-9 months
Primary tumour lung – 2-3 months
Almost all patients have recurrence within 3 years
Referral guidelines
Immediate investigation (same day)
◦ New onset weakness +/- sensory symptoms +/- autonomic symptoms
◦ Prescribe steroid + PPI
Urgent investigation
◦ Persistent severe back pain/nerve root pain without neurological symptoms if:
High risk group
Thoracic pain
Recumbent pain
Exacerbated by valsalva manoevre/Lhermitte’s sign
No investigation
◦
◦
◦
◦
Too frail for treatment
Very short life expectancy (weeks)
Already irradiated to tolerance or unfit for neurosurgery
So disabled, cord compression will not effect overall mobility
Key points
Common
Poor outcome unless early diagnosis
Pain is the key
Subtle motor changes
Neurological deficit is too late
Be aware of:
High risk groups
Clinical features
Hypercalcaemia in Advanced Cancer
The Commonest life-threatening
metabolic emergency associated with
advanced cancer
A condition which is usually amenable to
treatment
If untreated distressing and fatal
Always consider when there is
deterioration for no clear cause
Definition?
Hypercalcaemia
Defined
as corrected plasma calcium
>2.6mmol/l
Significant symptoms usually develop
above >3.0
Levels > 4.0 are fatal if untreated in a
few days
Hypercalcaemia
Incidence
◦ 10 – 20% of all cancer patients
◦ Up to 20% of patients develop
hypercalcaemia without bone metastases
◦ Common cancers: bronchial, breast,
myeloma, prostate
◦ Rare in gastric/colorectal cancer
Hypercalcaemia
Cause
/ risk factors:
◦ Bone metastases
◦ PTHrP – secreting tumours e.g. Lung
Cancer
◦ Dehydration, renal impairment
◦ Tamoxifen flare
Hypercalcaemia
Pathogenesis:
◦ Increased bone resorption (osteolysis) and systemic release of
humoral hypercalcaemic factors
◦ Calcium is released from bone, and in addition there is may be a
decrease in excretion of urinary calcium
Calcium release from bone by production of locally
active substances produced by bone metastases:
◦
◦
◦
◦
Parathyroid hormone related peptide,
Ectopic parathyroid secretion
Tumour mediated calcitriol production
(Some may occur with or without bone mets.)
Recognising Hypercalcaemia
General
• Dehydration
• Polydipsia
• Polyuria
• Pruritis
Neurological
• Fatigue
• Myopathy
• Psychosis
• Confusion
• Seizures
• Coma
Cardiac
GI
• Anorexia
• Weight loss
• Nausea and vomiting
• Constipation / ileus
• Bradycardia
• Atrial arrhythmias
• Ventricular arrhythmias
• Cardiac asystole
• Death
Prognosis
Indicates disseminated Disease
Poor prognosis 80% die within 1 year
Median survival is 3 to 4 months
Hypercalcaemia likely to recur
Hypercalcaemia
Treatment may not be necessary if:
the patient is very near to death
or
there are no symptoms distressing
the patient
Treatments of Hypercalcaemia
All treatments involve the correction of
serum calcium levels, which results in a
marked decrease in symptoms
Rehydration
Bisphosphonates
Steroids
Treatments of Hypercalcaemia
Rehydration:
Dehydration due to vomiting and
polyuria, large volume will lower
calcium levels, note fluid-overload!
2-3 L/day usually
Avoid concomitant use of diuretics,
Vitamin A and D which promote
hypercalcaemia
Treatments of Hypercalcaemia
Steroids:
◦ Have been shown to inhibit osteoclast
activity and calcium absorption from
the gut in vitro
◦ Limited to haematological and Breast
malignancies when oral prednisolone
40-100mg/day is usually effective
Treatments of Hypercalcaemia
Bisphosphonates
◦ Reduce bone resorption by inhibiting
osteoclast activity
◦ Highly effective
◦ But take 48 hours to be effective
◦ Mainstay of hypercalcaemia treatment
◦ Further benefit is that of reduction of bone
pain due to metastases
Treatment
Dehydration should be corrected with iv fluids
Most common choices of drug IV:
◦ Zolendronic Acid: 4mg over 15 minutes
◦ Disodium Pamidronate: 30-90 mg over 2-4 hours
Effect seen after 4 - 7 days
Lasts 2-4 weeks, many patients have monthly
infusions
20% patients with hypercalcaemia will be
resistant to infusion therapy
General EOL principles to follow:
Review patient regularly - holistically
Get District nurses involved early, others eg Macmillan
Inform Out of Hours, and practice team - & update!
Ascertain PPOC
Review symptoms and drugs
Communicate well with patient, family and carers
◦ Explain management of crises,
◦ whom to contact,
◦ use of 999,
◦ possible pathway for illness and symptoms expected when
deteriorates,
◦ ethical issues : nutrition, hydration, use of ab, oxygen,
◦ supportive measures available, financial help
◦ (DS1500)
Consider Just-in-Case medication
Consider DNACPR statement
All of the above - Adopt the Liverpool Care Pathway for holistic
management of the dying patient
Thank you
any Q
Dr Anant Sachdev
07976 608871
[email protected]