Agent		Mode of action	Indication in hypercalcemia	Cautions
Normal saline 2 to 4 L IV daily for 1 to 3 days		Enhances filtration and excretion of Ca++	Severe↑Ca++ > 14 mg per dL (3.5 mmol per L) Moderate↑Ca++ with symptoms	May exacerbate heart failure in elderly patients Lowers Ca++ by 1 to 3 mg per dL (0.25 to 0.75 mmol per L)
Furosemide (Lasix) 10 to 20 mg IV as necessary		Inhibits calcium resorption in the distal renal tubule	Following aggressive rehydration	↓K+, dehydration if used before intravascular volume is restored
Bisphosphonates Pamidronate (Aredia), 60 to 90 mg IV over 4 hours Zoledronic acid (Zometa), 4 mg IV over 15 minutes		Inhibits osteoclast action and bone resorption	Hypercalcemia of malignancy	Nephrotoxicity, ↓Ca++, ↓PO4, rebound↑Ca++ in hyperparathyroidism Maximal effects at 72 hours
Calcitonin (Calcimar or Miacalcin) 4 to 8 IU per kg IM or SQ every 6 hours for 24 hours		Inhibits bone resorption, augments Ca++ excretion	Initial treatment (after rehydration) in severe/Ca++	Rebound↑Ca++ after 24 hours, vomiting, cramps, flushing Rapid↑Ca++ within 2 to 6 hours
Glucocorticoids Hydrocortisone, 200 mg IV daily for 3 days		Inhibits vitamin D conversion to calcitriol	Vitamin D intoxication, hematologic malignancies, granulomatous disease	Immune suppression, myopathy
Plicamycin (Mithracin), 25 mcg per kg per day IV over 6 hours for 3 to 8 doses		Cytotoxic to osteoclasts	Rarely used in severe↑Ca++	Marrow, hepatic, renal toxicity
Gallium nitrate (Ganite) 100 to 200 mg per m2 IV over 24 hours for 5 days		Inhibits osteoclast action	Rarely used in severe↑Ca++	Renal and marrow toxicity